Telemedicine Consent Form

I _________________________(patient’s name) hereby consent to engaging in telemedicine with Daniel Jay Sonkin, Ph.D. as part of my psychotherapy. I understand that “telemedicine” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that telemedicine also involves the communication of my medical/mental information, both orally and visually, to health care practitioners located in California or outside of California.

The research to date suggests that telemedicine psychotherapy for depression, anxiety, trauma, interpersonal problems/anger management, substance abuse and other psychological disorders can be just as effective as in-person, face-to-face psychotherapy (Online therapy is having its moment). Successful therapy, whether done in person, via telephone or over the internet, depends on the knowledge and skill of the therapist and the strength of the client-therapist relationship. Although going to a therapist's office has its own unique advantages (such as, connecting in person, going somewhere neutral to discuss problems, getting away from the distractions of life), so does telemedicine psychotherapy. People who have been using telehealth during the stay-at-home orders this year, have discovered that telehealth psychotherapy is technologically easy, very convenient, free of travel time to and from the office, and, easy to fit into their work, travel and family schedules. As mentioned above, the most important factor in whether or not someone benefits from the therpeutic process is the client/s relationship with the therapist. The therapeutic relationship includes factors such as comfort with the therapist, trust of the therapist, and confidence in the therapist's skills and knowledge. And this trust, comfort and confidence can develop as easily over the telephone or via the internet.

With online or phone therapy, there is the question of where is the therapy occurring – at the therapist’s office or the location of the client? The law is not yet completely settled on this issue, therefore it is my policy to inform clients that they are receiving services from my online office (as if they were physically traveling to a physical office) and therefore are bound by the laws of the State of California. These laws are primarily related to confidentiality as outlined in this form and my disclosure form.

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

(1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

(2) The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; 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 written consent.

(3) I understand that there are risks and consequences from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychotherapist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.

In addition, I understand that some telemedicine-based services and care may not be as complete as face-to-face services (eg, psychological testing. I also understand that if my psychotherapist believes I would be better served by another form of psychotherapeutic services (e.g. face-to-face services) I will be referred to a psychotherapist who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my psychotherapist, my condition may not be improve, and in some cases may even get worse.

(4) I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured.

(5) I understand that I have a right to access my medical information and copies of medical records in accordance with California law.

I have read and understand the information provided above. I have discussed it with my psychotherapist, and all of my questions have been answered to my satisfaction.

Signature of patient/parent/guardian/conservator. If signed by other than patient indicate relationship

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