Telehealth Consent

TELEHEALTH INFORMED CONSENT

Taylor’d Therapy, LLC

Taylor Griffin, LCSW

1. Description of Telehealth Services

Telehealth involves the use of secure electronic communications technology to enable your Provider to deliver mental health services remotely. Telehealth services are conducted through a HIPAA-compliant platform (TherapyNotes).

To participate in telehealth, you must have:

• A reliable internet connection
• A device with video and audio capability
• Access to a private location where you can speak freely

Your Provider will explain how to access and use the telehealth platform. If telehealth is not clinically appropriate for you, alternative options or referrals will be discussed.

2. Licensure and Location Requirements

Taylor Griffin, LCSW, is licensed to provide services in the State of Wisconsin (or other licensed states, if applicable).

You must be physically located in a state where your Provider is licensed at the time of each session. You agree to inform your Provider of your physical location at the beginning of every telehealth session.

If you are located outside of a state where your Provider is licensed, services cannot be provided.

3. Potential Risks of Telehealth

While telehealth has many benefits, there are potential risks, including:

Privacy and Confidentiality

You may be required to provide identifying information (such as name, date of birth, contact information, and location) to access the telehealth platform. While the platform is HIPAA-compliant and reasonable safeguards are in place, no electronic communication system is completely secure.

You are responsible for ensuring that others cannot overhear your sessions and that your device is secure and password protected.

Technology Limitations

Technology failures may occur, including issues with internet connectivity, video, or audio. If technical difficulties arise:

• The session may continue by telephone.
• If issues cannot be resolved within a reasonable time, the session may be rescheduled.

Crisis or Emergency Situations

Telehealth may not be appropriate for crisis or emergency situations. It may be more difficult for your Provider to provide immediate assistance remotely.

You agree to:

• Provide your current physical address at the start of each session.
• Provide and maintain an up-to-date emergency contact.
• Develop an emergency plan with your Provider.

If your Provider believes you are at imminent risk of harm to yourself or others, and contact is lost or safety is uncertain, your Provider may contact emergency services or your designated emergency contact.

4. Potential Benefits of Telehealth

Telehealth may offer:

• Increased flexibility and convenience
• Greater access to care
• Reduced travel time
• Continuity of care during illness, weather disruptions, or other barriers.

5. Recording of Sessions

You may not audio or video record sessions without prior written consent from your Provider. Your Provider will not record sessions without your written permission.

6. Confidentiality

Confidentiality during telehealth sessions is protected in the same manner as in-person therapy and is subject to the same legal exceptions, including but not limited to:

• Risk of harm to self or others
• Suspected abuse or neglect
• Court orders or legal requirements

Please refer to the Notice of Privacy Practices for additional details regarding confidentiality and Protected Health Information (PHI).

7. Right to Withdraw Consent

You have the right to withdraw your consent to telehealth services at any time. Withdrawal will not affect your right to future care or treatment. If telehealth is discontinued, alternative options will be discussed.

Consent to Telehealth Services

By using taylordtherapy.com you acknowledge that:

* I have read and understand the information provided above.

* I have had the opportunity to ask questions about telehealth services.

* I understand the risks and benefits of telehealth.

* I agree to participate in telehealth services under the terms described above.