Clearview Mental Health Informed Consent for Telehealth Services

 

Introduction

Welcome to Clearview Mental Health. Before we begin providing telehealth mental health services, we require that all patients read and acknowledge this Informed Consent Form. This document provides essential information about our telehealth services and your rights as a patient.

 

Nature and Purpose of Telehealth Services

Telehealth involves delivering healthcare services using electronic communications, information technology, or other means between a healthcare provider and a patient not in the same physical location. Telehealth may include, but is not limited to, counseling evaluation, consultation, treatment planning, and resource referral.

 

Potential Benefits

- Increased accessibility to mental health care.

- Convenience of receiving care from your location.

- Access to specialized services that may not be available locally.

 

Potential Risks

- Limited or no physical examination during the visit.

- Technical difficulties that could disrupt the service.

- Possible limitations in privacy if technology fails.

 

Patient Rights

- You have the right to withhold or withdraw consent at any time without affecting your right to future care or treatment. You also have the right to inspect all information obtained and recorded during the telehealth interaction.

- You may expect the confidentiality of your information collected from telehealth services to be maintained.

 

Privacy and Security

Clearview Mental Health implements various security measures to protect your personal health information. However, despite our best efforts, security risks can only partially be eliminated.

 

Clearview Mental Health Informed Consent for Telehealth Services (cont.)

 

Text Messaging Opt-In

By signing this form, I voluntarily consent to receive text messages from Clearview Mental Health for appointment reminders, treatment coordination, and other healthcare-related information. I understand that standard text messaging rates may apply according to my service plan.

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Non-Marketing Guarantee

Clearview Mental Health will not sell or distribute my personal information for marketing purposes.

 

Legal Guardianship and Custodial Arrangements

I acknowledge that I am responsible for informing my provider of any legal guardianship or court-related documents before commencing care with Clearview Mental Health. By signing this document, I agree to promptly notify Clearview Mental Health of any custodial arrangements relevant to my telehealth services.

 

Parental/Guardian Communication

By signing this document, I understand that relevant information about parental or guardian communications will be shared with all appropriate parties as required by law or as deemed necessary for treatment and care coordination.

 

Consent

I have read and understand the information provided above regarding telehealth services. I hereby consent to participate in telehealth services with Clearview Mental Health.

 

 

Signature: ___________________________ Date: _______________

 

If the patient is under the age of consent or guardianship, parent or guardian signature:

 

Parent/Guardian Signature: __________________