Consent for Telehealth Services

I consent to engage in telehealth as part of my treatment with Elena Ho of Therapeutic Space LLP. I understand that “telehealth” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of personal health information, and education using interactive audio, video, or data communications.

I understand that I have the following rights with respect to telehealth:

• I have the right to withhold or withdraw this consent at any time. However, if I do so, this may require my therapist to provide referrals to other treatment providers, if face-to-face services are not an option based on geography and/or circumstance.
• The laws that protect the confidentiality of my personal health information also apply to telehealth, as do the limitations to that confidentiality discussed in the Services Agreement. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction will not be shared without my written consent.

I understand that there are unique risks and consequences with telehealth, despite reasonable efforts on the part of my therapist to avoid them. These potentially include:

• Transmission of my personal health information could be disrupted or distorted by technical failures
• Transmission of my personal health information could be interrupted by unauthorized persons
• Electronic storage of my personal health information could be accessed by unauthorized persons.

I understand I may be requested to install applications specific to treatment onto my phone, tablet or computer device. Some applications specifically interact via phone/tablet, device, etc. and have the capability to report activity, GPS location, etc.

In addition, I understand that telehealth based services may not be appropriate for everyone seeking therapy. I also understand that if my therapist believes I would be better served by another form of therapeutic services (e.g. face-to-face services) I will be referred to a practitioner who can provide such services in my area.

I understand that this form is signed in addition to the Services Agreement and that all policies and procedures within the Services Agreement apply to telehealth services.