PathForward Counseling

Informed Consent 

I hereby voluntarily consent to engage in teletherapy counseling services with PathForward Counseling Services.

I understand that "teletherapy" includes the, diagnosis, consultation, and treatment services using ecounseling methods  (live videotherapy). 

I understand that I have the following rights and understanding with respect to teletherapy:

1) I have the right to withhold or withdraw consent at any time without affecting my right to   

    future care or treatment nor risking the loss or withdrawal of any program benefits to which I   

    would otherwise be entitled.

2) I understand that my clinician is licensed is a licensed professional, giving him/her legal right  

    to provide teletherapy.

3) I understand that the dissemination to researchers or other entities shall not occur without my      

    written consent.  No personally identifiable information from my interaction with

    PathForward Counseling via teletherapy will be released without my written consent.   

3) Federal (HIPAA) and state laws protect the confidentiality information.  I understand that the  

    information I disclose to a PathFoward counselor is confidential. However, there are both  

    exceptions to confidentiality.  Although not a comprehensive list, some of the confidentiality

    exceptions are abuse of vulnerable populations.  PathForward Counseling

    may contact the appropriate authorities or persons should I express suicidal gestures or threats

    of violence towards another person.  If these situations occur, I understand that it is not  

    necessary that I have signed a release of information form in order for specific personal  

    information to be released to the appropriate authorities.   

4) I understand that there are risks and consequences from teletherapy. This includes, but is not    

    limited to, the possibility, despite reasonable efforts on the part of my counselor, that technical   

    failures could disrupt or distort the transmission of my medical information; unauthorized

    persons could interrupt the transmission of my medical information; and/or unauthorized

    persons could access the electronic storage of my medical information. In the event of a

    technical failure, I will have a contingency plan in place with my counselor for a back-up  

    mode of communication to close our therapy session and discuss next steps.  

    I understand that teletherapy-based services and care may not be as complete as in-person

    Face to-face services. I understand that if my counselor believes I would be better served by

    another form of psychotherapeutic services (e.g. face-to-face services) I will be referred to a

    psychotherapist who can provide such services in my area. Examples include, but are not

    limited to, crisis situations, severe and persistent mental illness, and medication management.

    Finally, I understand that there are potential risks and benefits associated with any form of

     psychotherapy, and that despite my efforts and the efforts of my psychotherapist, my   

     condition may not improve, and in some cases may even get worse.

5) I understand that I may benefit from teletherapy, but that results cannot be guaranteed or  

    assured. I accept that PathForward Counseling does not provide emergency services. During

    our first session, the counselor and I will discuss an emergency response plan. If I am

    experiencing an emergency situation, I understand that I can call 911 or proceed to the nearest

    hospital emergency room for help. Examples of emergency situations include, having thoughts

    of hurting either another person or myself, having hallucinations, being in a life-threatening or

    emergency situation of any kind, having uncontrollable emotional reactions, or being

    dysfunctional due to abusing alcohol or drugs. I acknowledge I have been told that if I am

    having suicidal thought or making plans to harm myself, I can 911 for support.

    I understand that my counselor may ask me to have a ‘collaborator’ on my premises, who is

    available to contact local authorities in an emergency. A collaborator can be family or friend.

    My counselor and I will determine who will be designated as my local collaborator, obtain

    their contact information and consent, discuss their responsibilities, and circumstances for

    contacting them.

6) I understand that I have a right to request access to portions of my medical information and

    copies of records in accordance with HIPAA privacy and security rules. I have read and

    understand the information provided above. I understand that I may discuss any of the above

    with my counselor, and have all of my questions have been answered to my satisfaction.