Google Meet is the Telehealth videoconferencing technology we will be using for our appointments. By signing this document I acknowledge:

1. Google Meet is not an emergency service. In the event of an emergency, I will use a phone and call 9-1-1. I understand that I can also call The Franklin County Netcare Emergency Response Services at (614) 276-2273.
2. Additionally, should I have a mental health crisis, experience thoughts of suicide or require other mental health crisis assistance, I can text 988 - Ohio's Crisis Lifeline. I will be connected to helping individuals trained to assist me in a timely manner.
3. Though my provider and I will be in direct, virtual contact using Google Meet, Google Meet does not provide any medical or healthcare services or advice, including but not limited to emergency or urgent medical services.
4. Google Meet facilitates videoconferencing and is not responsible for the delivery of healthcare, medical advice or care.
5. I do not assume or expect that my provider has access to all of the technical information about the Google Meet platform.
6. To maintain confidentiality, I will not share the Telehealth appointment link with anyone unauthorized to attend the appointment.

By signing this form I certify that:

1. I have read this form or had this form read and/or explained to me.
2. I fully understand its contents including the risks and benefits of receiving Telehealth through videoconferencing.
3. I have been given ample opportunity to ask questions, and that any questions have been answered to my satisfaction.
4. I agree to provide the environmental conditions outlined above to ensure a safe and confidential environment.