This form is designed to allow you to give informed consent for the use of video technology for online therapy. Read it thoroughly for understanding and ensure all of your questions are answered before signing to give consent

This is to be used in conjunction with, but does not replace, the Informed Consent document that is required of all clients prior to starting therapy services.

Online therapy or teletherapy is defined as the use of technology to have a therapy session. We will use Zoom, a HIPAA compliant platform that uses video and audio technology through a webcam on your device and my device to connect us securely.

The benefits of teletherapy include the convenience of location, time, wait times, and accessibility which allows for better continuity of care. In addition, teletherapy allows for greater accessibility to services for clients with limited mobility or with lack of transportation. Teletherapy can also allow for couples or families to meet when in different locations.

With all technology, there are also some limitations. Technology may occasionally fail before or during our session. The problems may be related to internet connectivity, difficulties with hardware, software, equipment, and/or services supplied by a 3rd party. Any problems with internet availability or connectivity are outside the control of the therapist and the therapist makes no guarantee that such services will be available or work as expected. If something occurs to prevent or disrupt any scheduled appointment due to technical complications and the session cannot be completed via online video, the therapist will either use the in-session video chat to trouble shoot or will call you back to complete the session.

If, for any reason, we are unable to connect and you are in an immediate crisis or a potentially lifethreatening situation, get immediate emergency assistance by calling 911.

In addition to contacting via telephone, there may be times the therapist may contact via email for scheduling, sending session material, etc. Confidentiality and security is not guaranteed through this form of communication and I understand these risks. I also understand this form of communication is not meant for therapeutic consultation.

I AGREE TO TAKE FULL RESPONSIBILITY FOR THE SECURITY OF ANY COMMUNICATIONS OR TREATMENT ON MY OWN COMPUTER OR ELECTRONIC DEVICE AND IN MY OWN PHYSICAL LOCATION. I also understand that I am responsible for using this technology in a secure and private location so that others cannot hear my conversation.

I AGREE TO PROVIDE THIS SAME LEVEL OF CONFIDENTIALITY FOR MY CHILD. I ALSO AGREE THAT I OR ANOTHER RESPONSIBLE ADULT IS PHYICALLY IN THE LOCATION DURING THIS TIME

I understand that there will be no recording of any of the online session and that all information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without my written permission, except where disclosure is required by law. I understand that I am not allowed to do any recording, screenshots, etc. of any kind, of any session, and are grounds for termination of the client-therapist relationship.

Consent to Treatment

I, voluntarily agree to receive online therapy services for an assessment, continued care, treatment, or other services and authorize Kay Phillips Child Advocacy Center to provide such care, treatment, or services as are considered necessary and advisable. I understand and agree that I will participate in the planning of my care, treatment, or services and that I may withdraw consent for such care, treatment, or services that I receive through Kay Phillips Child Advocacy Center at any time. I understand Kay Phillips Child Advocacy Center will determine on an on-going basis whether the condition being assessed and/or treated is appropriate for online therapy.

After Hours/Crisis Intervention Services

If you need to speak with your clinician between sessions to alert them of an emergency, please call the main office at 843-875-1551. Your call will be returned as soon as possible. Messages are checked throughout the day.

Kay Phillips Child Advocacy Center is not a 24-hour crisis intervention provider. Clinicians do not provide crisis counseling or emergency services related to mental health needs. If you believe that you, your child, family member or legal dependent is in immediate danger of harm to self or others, please call 911 immediately. You can also seek assistance from Mobile Crisis, which is provided by South Carolina Department of Mental Health. For Berkeley County Residents please call: 1-833-364-2274 for Dorchester/Charleston Residents please call: 843-414-2350. You may also call the National Alliance on Mental Illness at 1-800-950-6264 or text “NAMI” to 741741.

Should you seek emergency treatment from another provider, we encourage you to keep your clinician updated regarding any treatment received as these may impact treatment.

By signing this Informed Consent, I, the undersigned client, acknowledge that I have both read and understood all the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.