INFORMED CONSENT FOR ONLINE THERAPY & COMMUNICATIONS
I understand that therapy conducted online is technical in nature, & that problems may occur with internet connectivity. Internet availability may be limited or disrupted by things such as server maintenance, upgrades, or other problems (such as software or hardware malfunction). Any problems with internet availability or connectivity are outside the control of Foley L. Nash, LPC-S, LMFT-BAS (hereinafter referred to as therapist), who therefore can make no guarantee that such services will be continuously available. If something occurs to prevent or disrupt any scheduled appointment due to technical complications, & the session cannot be completed via telephone, a new appointment will be re-scheduled. Please note, however, that if a session is disrupted for technical reasons, therapist, at his sole discretion, may resume the session by telephone. All sessions disrupted for over 15 minutes, but less than the full session time may be charged at a prorated amount.
I understand that if either I or the therapist communicates using a cell phone that the conversation may not be secure, & therefore not guaranteed confidential. In the event that our online session is disrupted, it will be most secure for us to continue the session when we both are on a land line, if it is available.
Please note that the therapist has a 24-hour cancellation policy. Should you miss or cancel an appointment within the 24-hour window, you may be charged for the session. Please read the therapist’s Declaration of Practices & Procedures document (which includes office policies & procedures) for additional information.
Information About Mr. Nash’s Secure Electronic Record Site: To register as a client on the secure electronic record site, go to www.foleynash.com, open the Client Info Page, & use the link marked View Appointment Calendar. That link will offer the following options:
to login if you are already registered, & if not,
to register as a new client, as well as to see appointment availability.
Upon registering, you:
create your own login/password,
have access to online scheduling options,
can use confidential, encrypted communication through the site, &
can set up various types of confidential appointment reminders.
Email Communications: I understand that email communications with the therapist via the electronic record site are encrypted, & that emails sent from or to personal email accounts are not secure. I also understand that the therapist may not check personal email regularly. I further acknowledge and agree that all communication of a clinical nature should be sent via the site. A reasonable attempt will be made to read and respond timely to the emails received via the site (i.e., within 24 to 48 hours).
I further acknowledge & understand that the therapist cannot always appropriately respond to personal & clinical concerns via regular email or texting. Regular email should not be used in the event of a crisis or an emergency. I acknowledge that the therapist may charge me (or the third-party payor) the fees (if any) set forth in the therapist’s office policies & procedures or fee schedule (or otherwise established & agreed upon) to communicate with me regarding clinical service via emails through the electronic record site.
I understand that the therapist cannot, for ethical reasons, accept my invitations via social media websites, networking websites, instant messenger, or respond to blogs written by me, or accept my comments on his/her blog.
I understand that if I need to speak with the therapist between sessions, I should call 985-774-3252. My call will be returned as soon as possible. I acknowledge that messages are generally checked daily, but sometimes with less frequency at night, on weekends, & on holidays.
If an emergency situation arises that requires immediate attention, I should:
call the Emergency National Hopeline Network at 1-800-Suicide/1-800-784-2433 or
call the National Suicide Prevention Lifeline at 1-800-Talk /1-800-273-8255 or dial 911.
Hearing & Speech Impaired should call 1-800-799-4TTY/1-800-799-4889.
I understand that in the event of a life-threatening crisis I should contact a crisis hotline, call 911, or go to the nearest hospital emergency room.
Additionally, although the therapist has taken substantial steps to ensure the confidentiality and privacy of therapy provided online, the therapist cannot guarantee the security of any internet transmissions or communications. I AGREE TO TAKE FULL RESPONSIBILITY FOR THE SECURITY OF ANY COMMUNICATIONS OR TREATMENT ON MY OWN COMPUTER & IN MY OWN PHYSICAL LOCATION. I understand that all information disclosed within sessions, & any written records pertaining to those sessions are confidential, & as such, may not be revealed to anyone without my written permission, except where disclosure is required by law.
Initial to agree:
__AD____ I understand that online therapy with me is not a substitute for medication under the care of a psychiatrist or doctor. I further understand that online therapy is not appropriate if I am experiencing a crisis, or if I am having suicidal or homicidal thoughts.
__AD____ I agree to release & indemnify the therapist from & against all damages, costs, suits, claims, & other actions originating from teletherapy services provided to me by said therapist.
__AD____ I understand & agree that at each teletherapy session, for safety & security purposes, I will need to provide (or reconfirm) the following items of information to the therapist:
a. My Name: already on file
b. My physical location that day: Home
c. My Parish (for local 911 number): Lincoln
d. My phone # for backup contact, if needed: on file
e. The Nearest Emergency Room (ER): in parish
f. The ER Contact: Local 911 # = 318-251-8695
g. Other participants present, with my approval: ______________________
COMMUNICATIONS: PERMISSION TO CONTACT FORM
I authorize Foley L. Nash, LPC-S, LMFT-BAS to contact me, &/or leave a message concerning appointments, administrative items, or emergency issues via the following methods (please check all methods that you approve and provide the appropriate contact information in the space provided):
__X____ Information is already entered in the electronic record (Any additions/changes should be noted below).
Voice Mail (home)
Voice Mail (cell)
Voice Mail (work)
Text Message (not encrypted)
Email (not encrypted)
Postal Mail (address)
NOTE: Every attempt will first be made to contact you through the encrypted communication system of Mr. Nash’s electronic record site that meets HIPAA/HITECH regulations.
Signature of Patient/Client Date
Signature Parent, Guardian or Legal Representative Date
Completed forms may be returned by fax, email, or postal mail to Mr. Nash at the central mail address below, or delivered when meeting in person at any of the physical service locations shown below.
For greater protection with email, you can send documents password -protected, & send the password separately.
Foley L. Nash, LLC, dba Foley L. Nash, LPC-S, LMFT-BAS
Fax: 985-18-07444 E-mail: email@example.com or firstname.lastname@example.org
Mail: 9655 Perkins Rd., Ste C-170, Baton Rouge, LA 70810
Physical Service Locations:
6160 Perkins Rd. Ste # 207, Baton Rouge, LA 70808 (NEW, effective June 1,2020)
769 Robert Blvd, Ste 201 B, Slidell, 70458