Your privacy when using telemedicine is taken seriously.



Whether we agree now or later to use the telephone or telehealth video conferencing in place of in-person therapy, whether regularly or occasionally, please read and sign this form.


Therapy conducted over the phone, or telehealth therapy which is therapy provided through online videoconferencing technology, enables the therapist and client to be in separate locations at the time of service. Your rights still apply and have been listed below. Please note that the term “telemedicine” will encompass therapy conducted over the phone as well as through videoconferencing.  


(1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment or risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.


(2) The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality including, but not limited to: reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. (See also Office Policies and HIPAA Notice of Privacy Practices forms, provided to me, for more details of confidentiality and other issues.)


I also understand that the dissemination to researchers or other entities, of any personally identifiable images or information from the telemedicine interaction shall not occur without my written consent.


(3) I understand that there are risks and consequences from telemedicine. These may include, but are not limited to, the possibility, despite reasonable efforts on the part of my psychotherapist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; the electronic storage of my medical information could be accessed by unauthorized persons; and/or misunderstandings can more easily occur, especially when care is delivered in an asynchronous manner.


In addition, I understand that telemedicine-based services and care may not yield the same results nor be as complete as face-to-face service. I also understand that if my psychotherapist believes I would be better served by another form of psychotherapeutic service (e.g. face-to-face service), I will be referred to a psychotherapist in my area who can provide such service. 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.


(4) I understand that I may benefit from telemedicine, but results cannot be guaranteed or assured. The benefits of telemedicine may include, but are not limited to: finding a greater ability to express thoughts and emotions; transportation and travel difficulties are avoided; time constraints are minimized; and there may be a greater opportunity to prepare in advance for therapy sessions.


(5) I understand that I have the right to access my medical information and copies of medical records in accordance with California law, that these services may not be covered by insurance, and that, if there is intentional misrepresentation, therapy will be terminated.



Telehealth via SimplePractice is the technology service that will be used to conduct telehealth videoconferencing appointments. By signing this document, I acknowledge:

  1. Telehealth via SimplePractice is NOT an emergency service and in the event of an emergency, I will use a phone to call 911.

  2. Though my provider and I may be in direct, virtual contact through the telehealth service, neither SimplePractice nor the telehealth service provides any medical or healthcare services/advice including, but not limited to, emergency or urgent medical services.

  3. The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.

  4. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.



By my consent, I certify:

  • That I have read or had this form read and/or had this form explained to me.

  • That I fully understand its contents including the risks and benefits of the procedure(s).

  • That I have been given ample opportunity to ask questions.