Foley L. Nash, LLC, Counselor: Foley L. Nash, LPC-S, LMFT-BAS
MAIL: 9655 Perkins Rd., Suite C-170, Baton Rouge, LA 70810
Phone: 985-774-3252 Fax: 985-718-0744 Email: email@example.com
Teletherapy Declaration & Informed Consent (3 pages)
(An additional document to the normal declaration of practices used for in-person sessions)
Information for Clients:
Licensed mental health professionals are required by their licensing boards to provide you, the client, with certain basic information. You may have already received and signed the basic Declaration of Practices and Procedures from Mr. Nash. This Teletherapy Policy and Procedure document describes certain important aspects of therapy unique to teletherapy. This information is provided for your review and agreement. Please take time to read it carefully, and discuss any questions you have before signing below.
By signing this form, you are not making a commitment to continue teletherapy as your permanent mode of therapy, but you will continue to have that option should you and I agree that it is in your best interest.
QUALIFICATIONS OF CLINICIAN
I have completed 21+ hours of live telehealth training in addition to my professional qualifications as a clinician. This training covered the law and ethics and clinical skills specifically related to telehealth care. I will continue to receive at least 3 hours of continuing education in telemental health every 2 years. All teletherapy sessions will be conducted through the HIPAA-compliant services of either C3Now (a stand-alone service) or the services of therapyappointment.com, both encrypted to the federal standard.
SCHEDULING AND STRUCTURE OF TELETHERAPY
Counseling sessions will be scheduled in 50-minute increments, unless you and I agree on a different time schedule. The next session will be scheduled at the end of the current session, unless otherwise agreed upon. The structure of sessions will be dependent on the treatment plan and interventions being used.
ETHICAL AND LEGAL RIGHTS RELATED TO TELETHERAPY
Mr. Nash will not be conducting teletherapy in any other state than Louisiana unless he specifically seeks and obtains licensure in the other state. It is important for you as a client to realize that if you should relocate to another state, Mr. Nash’s ability to conduct or continue teletherapy would be dependent on his decision whether to seek licensure in the state to which you are relocated.
RESPONSIBILITIES OF THE CLIENT
- be appropriately dressed during sessions.
- avoid using alcohol, drugs, or other mind-altering substances prior to session.
- be in a safe and private area appropriate for a teletherapy session.
- make every attempt to be in a location with stable Internet capability.
Clients should not:
- record sessions unless first obtaining Mr. Nash’s permission
- have any anyone else in the room unless you first discuss it with Mr. Nash
- conduct other activities while in session (such as texting, driving, etc.)
If the client is a minor, the parent or guardian must be present at the location or building of the teletherapy session, unless otherwise agreed upon with the therapist.
POTENTIAL COUNSELING RISKS
When using technology to communicate on any level, there are some important risk factors of which to be aware. It is possible that information might be intercepted, forwarded, stored, sent out, or even changed from its original state. It is also possible that the security of the device used may be compromised. Using methods of electronic communication with counselors outside of our recommendations creates a reasonable possibility that a third party may be able to intercept that communication. It is your responsibility to review the privacy section and agreement forms of any application and technology. Please remember that depending on the device being used, others within your circle (family, friends, employers, and coworkers, as well as those not in your circle (criminals, scam artists, etc.) may have access to your device. Reviewing the privacy sections for your devices is essential. Please contact me with any questions that you may have on privacy matters.
POTENTIAL LIMITATIONS OF TELETHERAPY
Teletherapy is an alternate form of counseling, and it should not be viewed as a substitution for taking medication that has previously been prescribed by a medical doctor. It has possible benefits and limitations. By signing this document, you agree that you understand that:
- Teletherapy may not be appropriate if you are having a crisis, acute psychosis, or suicidal/homicidal thoughts.
- Misunderstandings may occur due to a lack of visual and/or audio cues.
- Disruptions in the service and quality of the technology used may occur.
- NOTE (re billing & 3rd-party payments): I can file insurance claims, & I can also make an invoice available to you to file with your insurance company. While most policies now cover teletherapy, please check ahead of time to be sure your policy covers telemental health counseling.
The following items or important and necessary for your safety. The clinician will need this information to get you help in the case of an emergency. By signing this consent to treatment form you acknowledge that you have read, understand, and agree to the following:
- The client will inform Mr. Nash of the physical location where he or she is, and that will be used consistently while participating in sessions, and will inform Mr. Nash if this location changes.
- In the first teletherapy session, you will provide the name of a person Mr. Nash is allowed to contact in case he believes you are at risk.
- You will be asked to sign a release of information for this contact.
- In the first teletherapy session, you will provide information about the make, model, color, and tag number of your automobile.
- In each session, you will provide (or confirm) information about the nearest emergency room or emergency services, such as fire station, police station, etc. if there is not an emergency room nearby.
- Depending on the assessment of risk, and in the event of an emergency, you or Mr. Nash may be required to verify that the emergency contact person is able and willing to go to the clients location and if that person deems necessary, call 911 and/or transport the client to a hospital.
- In addition to this Mr. Nash may assess, and therefore require, that you, the client, create a safe environment at your location during the entire time of treatment.
- If an assessment is made for the need of a safe environment, a plan for this safe environment will be developed at the time of need, and made clear by Mr. Nash.
- In the case of a need to speak to Mr. Nash between sessions, please call or text, and leave a message. Nash does not provide emergency services on a 24-hour basis. If your emergency is after hours, please contact your nearest emergency room. With some exceptions, typically contact between sessions is limited to arranging for appointments.
- If you need the services of other professionals, Mr. Nash is happy to consult and coordinate with them. Clients should not routinely be meeting with more than one counselor, unless the two counselors have agreed to coordinate your care.
BACKUP PLAN IN CASE OF TECHNOLOGY FAILURE
The phone is the most reliable backup option in case of technological failure. It is highly recommended but you always have a phone at your disposal, and that Mr. Nash knows your phone number. If disconnection from a video conference occurs, end the session, and Mr. Nash will attempt to restart the session. If reconnection does not occur within 5 minutes, call Mr. Nash at the contact number that has been provided. If within 5 minutes Mr. Nash does not hear from you, you agree (unless otherwise requested) that he can call the provided phone number.
CONSENT TO TELETHERAPY TREATMENT
I have read and understood this Declaration of Teletherapy Policies & Procedures, and I have a copy for reference. My signature below indicates my full informed consent to services provided by Mr. Nash via teletherapy treatment.
DATE Client Signature 1 DATE Client Signature 2
DATE Client Signature 3 DATE Client Signature 4
Parental Authorization For Minors:
(Signature of Parent/Guardian) DATE
give my permission for Foley Nash, LPC-S, LMFT-BAS, to conduct counseling with
(Relationship of Minor) Name of Minor (please print)
Options for recording your signature:
- You may sign this document while Mr. Nash is watching via video, or
- You may scan the signature page, and send it via text to Mr. Nash, or
- You may snap a picture and send it via text to Mr. Nash, or
- You may mail your signed document, sending it to the address at the top of this document.