ONLINE MENTAL
HEALTH COUNSELING INFORMED CONSENT
Welcome to my practice. This document contains important
information about my professional services and business
policies. Please read it carefully and jot down any questions
you might have so that we can discuss them at our next meeting.
When you sign this document, it will represent an agreement
between us.
Confidentiality As a nationally certified and a state licensed
mental health counselor, I adhere to a code of ethics that
insures your privacy and confidentiality. Nothing you disclose
is shared with anybody, either verbally or in written form. Your
contact information is not shared with anyone. Should there be a
need to share such information, it can only occur based on your
written consent. There are some important exceptions to this
rule. I am legally and ethically bound to breach confidentiality
and report to proper authorities if I suspect that you are a
clear and present danger to yourself or anyone else. I am
obligated to warn any person who may be in danger from your
actions. I am bound by law to report any suspected child abuse
or elder abuse. In the case of court proceedings involving a
client, I may be subpoenaed to release confidential information
or if I am the defendant in a client initiated lawsuit or
malpractice claim I may be required to breach confidentiality.
Outside of these very rare exceptions, all counseling session
communications are strictly confidential. Although I may at
times feel the need to obtain peer supervision regarding some
issues relating to information brought forth in a session, the
client is not identified in any way. The client is the holder of
Privilege, which basically means that all counseling session
communications belong to the client. The client, in writing,
must explicitly approve any release of information outside the
exceptions listed above.
Security Chance for Happiness utilizes password- protected
computers with a full array of security software including
anti-spam, anti-hacker, anti- malware, and anti-ad as well as a
robust firewall. Online counseling is conducted in a private
office. All clients who participate in Chance for Happiness are
required to acknowledge their understanding of privacy and
confidentiality. This is referred to as “informed consent.” If
your computer does not have security systems such as anti-virus,
anti- malware, etc., or you access a public computer for online
counseling, you can help ensure privacy by using a free secure
web based email system such as safe- mail or Hush mail. The use
of such email programs is not required but recommended as part
of informed consent relating to security of online counseling.
For security while using live chat/instant messaging, consider
Pidgin OTR (Off-the-Record) or Chat Crypt. Another program to
consider for chat, voice and video encryption is Jitsi. For
these security encryption programs to work, both parties need to
be using the same program. Despite safeguards, absolute
confidentiality and privacy cannot be guaranteed over the
Internet.
Special Concerns
Online counseling has some unique challenges. By law, a minor
must have parental consent to participate in counseling.
Obviously, it is not difficult for a minor to pass as an adult
on the Internet. As such, part of online counseling informed
consent is the acknowledgement that a person requesting
counseling sessions is an adult. Should a minor wish counseling
sessions, parental consent must be obtained through email and
verified through phone contact.
Because there is always the possibility of technology failure
and computer crashes, alternate modes of communication are
recommended, but not required. Should power or technology
failures occur, it is assumed counselor and client will
reconnect once those failures have been rectified.
Last, but by far not the least of special concerns, is the issue
of misunderstanding. Because online text based counseling is
devoid of so many vocal and visual cues and clues,
misunderstanding is possible. Every attempt is made to be as
clear and straight forward as possible. Nevertheless, if a
misunderstanding does occur, it will be up to the client and the
counselor to work out a satisfaction.
By signing this form and by engaging in online counseling with
Chanceforhappiness, LLC I understand the following:
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I understand
that the laws that protect privacy and the confidentiality
of medical information also apply to telemedicine. I
understand that the information disclosed by me during the
course of my treatment is generally confidential. However,
there are both mandatory and permissive exceptions to
confidentiality, including but not limited to information
demonstrating a probability of imminent physical injury to
myself or others; immediate mental or emotional injury to
myself; and where I make my mental or emotional state an
issue in a legal proceeding. I also understand that the
dissemination of any personally identifiable images or
information from the telemedicine interaction to researchers
or other entities shall not occur without my consent.
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I understand
that I have the right to withhold or withdraw my consent to
the use of telemedicine in the course of my care at any
time, without affecting my right to future care or
treatment.
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I understand
that I have the right to inspect all information obtained
and recorded in the course of a telemedicine interaction,
and may receive copies of this information for a reasonable
fee.
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I understand
that a variety of alternative methods of medical care may be
available to me, and that I may choose one or more of these
at any time. I understand that I may ask my Treatment
Provider about alternative methods of care to telemedicine.
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I understand
that telemedicine may involve electronic communication of my
personal medical information to other medical practitioners
who may be located in other areas, including out of state.
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I understand
that it is my duty to inform my Treatment Provider of
electronic interactions regarding my care that I may have
with other healthcare providers.
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I understand
that telemedicine based services and care may not be as
complete as face-to-face services. I also understand that if
my Treatment Provider believes I would be better served by
another form of service (e.g. face-to-face services), I will
be referred to a Treatment Provider who can provide such
services in my area. Finally, I understand that there are
potential risks and benefits associated with any form of
treatment, and that despite my efforts and the efforts of my
Treatment Provider, my condition may not improve, and in
some cases may even get worse.
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I understand
that I may expect the anticipated benefits from the use of
telemedicine in my care, but that no results can be
guaranteed or assured.
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I understand
that in the event of an adverse reaction to the treatment,
or in the event of an inability to communicate as a result
of a technological or equipment failure, I shall seek
follow-up care or assistance at the recommendation of my
Treatment Provider.
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Have read the
information about privacy understand your rights of
confidentiality.
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Are 18 years
of age or older.
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Understand
that if you are initiating a session for a minor and you are
the parent or legal guardian, you must first email at
chanceforhappiness.com and provide the name and email
address of the minor along with a statement of your consent
for service. You must also include a telephone number where
you can be reached to verify consent.
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Have been
alerted to the issue of Internet security (Privacy
statement) and have been advised on the need for antivirus,
anti-spam, anti-hacker and firewall software for your
computer. You have been advised of a free, secure web based
email system (www.safe-mail.net) or (www.hushmail.com).
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Understand
that despite safeguards such as security software and
passwords, Internet confidentiality cannot be absolutely
guaranteed.
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Understand
that Chanceforhappiness reserves the right to refuse
participation in communication, which is not deemed
therapeutic.
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Understand
that ChanceforHappiness is not liable for how individuals
respond to or utilize information presented during
therapeutic communications.
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Understand
that ChanceforHappiness may present case information to
professional peers for consultation. In such instances, no
identifiable client information is disclosed.
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Understand the
fee for service rates and how to make payments.
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Agree that by
contacting the counselor Chanceforhappiness for the purpose
of therapeutic dialogue indicates that you have read this
page and are in agreement with its stipulations.
While this written summary of exceptions to confidentiality
should prove helpful in informing you about potential problems,
it is important that we discuss any questions or concerns that
you may have at our next meeting. I will be happy to discuss
these issues with you if you need specific advice, but formal
legal advice may be needed because the laws governing
confidentiality are quite complex, and I am not an attorney.
Your electronic signature during the sign up process indicates
that you have read the information in this document and agree to
abide by its terms during our professional relationship. I
ACKNOWLEDGE RECEIPT Of This Notice Of Privacy Practices.
Laurie D. Lerner MS. LMHC MH#7805 – Chance For Happiness LLC
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