Agreement for Tele-Therapy Services Consent

I acknowledge that Wellness Wag will provide administrative services to connect me with a licensed mental health professional (“the LMHP”) via their online platform for behavioral healthcare, including assessment, diagnosis, therapy, follow-up, and/or education. Teletherapy includes consultations, treatments, the transfer of personal and health information, emails, telephone conversations, and education using interactive audio, video, and data communications (“Telehealth”). Telehealth involves the use of electronic communications. I hereby consent to engage in Telehealth services with my LMHP. I understand that my LMHP is an independent contractor and is not employed by Wellness Wag. My LMHP may require me to execute an additional informed consent before engaging in Telehealth.

I understand that the expected benefits of Telehealth include improved access to behavioral health care, enabling me to remain at a remote site while the LMHP is at a distant site, more efficient evaluation and management, and obtaining the expertise of a distant LMHP who is licensed in the state where I reside.

I understand that I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my personal and health information for in-person behavioral health services. Any information disclosed by me during the course of my remote Telehealth, therefore, is generally confidential to the extent provided by law.

As with any medical care, there are potential risks associated with the use of Telehealth. These risks include, but may not be limited to: (a) in rare cases, information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate professional decision-making by the LMHP; (b) delays in evaluation and treatment could occur due to deficiencies or failures of the equipment; and (c) the possibility of disruption, distortion, or unauthorized access during transmission of personal information due to internet/electronic/technical failures beyond the control of Wellness Wag and my LMHP.

By signing this form, I understand the following:

• I understand that Telehealth is the use of electronic communication technologies by a health and/or therapeutic provider to deliver services to an individual when they are located at a different site than the provider; and hereby consent to the LMHP providing mental and social services to me via Telehealth.
• I understand that I may be required to have certain system requirements to access electronic Telehealth services via the chosen method. I understand that I am solely responsible for any cost to obtain any additional/necessary system requirements, accessories, or software to use tele-behavioral health services.
• I understand that I have the right to withhold or withdraw my consent to the use of Telehealth by the LMHP at any time, without affecting my right to future care or treatment.
• I understand that a variety of alternative methods of health care may be available to me, and that I may choose one or more of these at any time.
• I represent and warrant that all required information I provided to Wellness Wag and the LMHP is truthful and accurate, and that I will maintain the accuracy of such information.
• I understand that there are, by law, exceptions to confidentiality by an LMHP including, but not limited to, reporting child, elder, and dependent adult abuse; expressed threats of violence toward an identifiable victim; my own mental or emotional state informing a clear danger to myself or others; where I make my mental or emotional state an issue in a legal proceeding; where otherwise required by law.
• I understand that I am solely responsible for the privacy and confidentiality in my surrounding environment while engaged in Telehealth and will exercise appropriate privacy measures.
• I agree that if it becomes clear to the LMHP, in their sole professional opinion, that the Telehealth modality is unable to provide all pertinent clinical information during the Telehealth encounter, the LMHP will advise me prior to the conclusion of the live Telehealth encounter and will advise me regarding the need for an additional in-person evaluation reasonably able to meet my needs and may make a referral to an LMHP in my area.
• I understand that I have a duty to inform my LMHP of electronic interactions regarding my care that I may have with other healthcare providers.
• I understand that Telehealth services may not be as complete as face-to-face services.
• I understand that there are potential risks and benefits associated with any form of treatment, and despite my efforts and the efforts of my LMHP, my condition may not improve, and in some cases may even get worse.
• I have been given an opportunity to select an LMHP prior to the consult, including a review of the consulting provider’s credentials.
• I understand there is a risk of technical failures during the Telehealth encounter beyond the control of Wellness Wag or my LMHP. I agree to hold harmless Wellness Wag and my LMHP for delays in evaluation or for information lost due to such technical failures.
• I understand that if I am experiencing a medical emergency or a crisis, I should dial 9-1-1 or contact the National Suicide Hotline at 800-273-TALK (800-273-8255) immediately, as appropriate, and that Wellness Wag is not able to connect me directly to any local emergency services or crisis hotline.
• I understand that Wellness Wag does not guarantee that your LMHP will issue an Emotional Support Animal letter or that a landlord, airline, or other third party will accept your ESA Letter.
• I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes.
• I have read and understand the information provided above regarding Telehealth and all of my questions have been answered to my satisfaction. By clicking the “I AGREE” button and typing my name at the bottom of this page, I am authorizing the LMHP to whom Wellness Wag facilitates a connection to assess my mental health via Telehealth and confirming my agreement and understanding of the statements above. I hereby give my informed consent and authorization for my LMHP to use Telehealth in my healthcare.

I agree that a copy of this form may be treated as a signed original.

This authorization will remain valid until revoked by me in writing or as provided by law, whichever occurs first. A copy of this authorization will be as valid as the original.