This consent is an addendum to our original Treatment Consent and Fee Agreement Forms

• The policies outlined in those original documents, including appointment cancellations, how to contact your provider, emergencies, and crisis protocols, are still in effect.
• The Franklin County Psychiatric Emergency line: Netcare Emergency Response Services at (614) 276 2273
• Google Meet is a HIPAA-compliant telehealth platform that uses advanced AES 128-bit encryption.
• Our local effort and cooperation will help reduce the risks associated with infection for our families, friends, clients, and colleagues and not unnecessarily overwhelm our healthcare system.

Participating in Telehealth services requires that the client agree to the following:

• The client will provide their own technology (including a secure internet connection, video/webcam, microphone, and audio). A smartphone will work, but it is not ideal.
• The client agrees to originate their appointment from a non-public location that allows privacy and minimizes the ability of the appointment to be overheard. Consider using a white noise machine outside the room if you think you might be overheard by others. It is strongly recommended that the client use earphones/earbuds if privacy is not available.
• Please place a “do not disturb” notice on the closed-door room you will use.
• The client agrees to not initiate their Telehealth appointment in a public place while driving a car, using public transportation, or being a passenger in a car.
• The client agrees to participate in Telehealth services dressed appropriately as if they were attending in-person appointments.
• If the client does not uphold the expectation of providing a safe and confidential space, the appointment could be ended.
• You DO NOT have to set up a Google Meet account. However, you may need to download the Google Meet App on your phone, computer, or iPad/tablet. Multiple web browsers are supported and it works with iPhones and Androids.

Consent for Telehealth Services

1. I understand that my provider has offered me Telehealth Services.
2. I understand that the information transmitted during Telehealth Services will not be recorded.
3. My provider has explained that receiving services using video conferencing will not be the same as an in-person office visit due to the fact that | will not be in the same room as the provider.
4. I understand that Telehealth services have potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
5. I understand that there are potential risks to Telehealth including interruptions, unauthorized access, and technical difficulties.
   1. I understand that if there is a service disruption due to technology failure, my provider will contact me by telephone to continue the appointment in this format.
   2. I understand that the provider or I can request to discontinue the Telehealth services if it is agreed that the video-conferencing connections are not adequate for this situation.
6. I understand I can have a direct conversation with my provider, during which I can ask questions about Telehealth services.