Telehealth Informed Consent

Now Offering: Virtual (Remote) Counseling & Outpatient Services

Addiction does not take time off during a crisis, and we continue our mission to provide caring and effective addiction counseling during this period of social distancing.

We accept new clients (and continuing our treatment of existing outpatient clients) through remote Telehealth meetings. This way, we can continue ‘face to face’ treatment while observing social distancing. We utilize Zoom software to facilitate these meetings. Once you download and install the software, we will send you the link to join your counseling session.

Our virtual processes can include:

• Group therapy
• Individual therapy
• Intakes & Assessments
• Psychiatric & health evaluations
• Family sessions
• Case Management

‘In-Person Treatment’ Continues: We are also still providing ‘in-person’ detox and residential treatment and have implemented new protocols to respond to the threat of COVID-19 (read more)

Telehealth Informed Consent

To Download and Sign Our Informed Consent, Click Here.

1. Purpose and Benefits.

Telehealth is online or virtual counseling. As a part of telehealth sessions, you will access our services while you are at home via a HIPAA compliant video platform and will exchange protected health information. The information that is exchanged may be used for diagnosis, counseling, follow-up, and/or education and may include any of the following:

• Patient medical records
• Live two-way audio and video.

We will provide telehealth services using Zoom Video Conferencing for Telehealth. The telehealth consultation will be similar to a group. Individual sessions at the office, except interactive video technology, will allow you to communicate with counselors and therapists at a distance. At first, you may find it difficult or uncomfortable to communicate using online video-setting. Our staff will assist you to be able to access our telehealth services as smooth as possible.

2. Potential Risks and Service Limitations:

• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
• In rare events, the provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth session or a referral to a local psychologist or counselor as applicable.
• In rare events, security protocols could fail, causing a breach of personal health information privacy.
• Our providers do not address urgent cases or medical emergencies. If you believe you are experiencing a medical emergency, you should dial 911 and/or go to the nearest urgent care center or emergency room. After receiving an urgent healthcare treatment, you should visit your primary care doctor.

3. Client’s Responsibilities

• Understand your individual & group session schedule and attend all scheduled sessions punctually. Inform the counselor about your absence before the session.
• Use secure internet source and devise with a private setting.
• Do NOT share meeting information/passwords outside of group members.
• Do not discuss group issues outside of group sessions.

4. Client’s Rights.

You may withhold or withdraw consent to the telehealth consultation at any time without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. You have the option to consult with your counselor in person if you travel to his or her location.

5. Consents

• I hereby consent to receive Cycles of Change Recovery Services’ services via telehealth technologies. I understand that Cycles of Change Recovery Services and its providers offer telehealth-based substance abuse-related educational/counseling/psychotherapy services. Still, these services do not replace the relationship between my primary care doctor and me. I also understand it is up to the Cycles of Change Recovery Services provider to determine whether my specific clinical needs are appropriate for a telehealth encounter.
• I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that Cycles of Change Recovery Services will take steps to ensure that my health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of my personal health/mental related information to other health practitioners who may be located in other areas.
• I understand the importance of complying with Cycles of Change Recovery Services’ Group Confidentiality Policies and make the best effort to comply with the policy. I further understand that group confidentiality in telehealth sessions relies on the group members’ dignity and compliance.
• I understand there is a risk of technical failures during the telehealth encounter beyond the control of Cycles of Change Recovery Services. I agree to hold harmless Cycles of Change Recovery Services for delays in evaluation or information lost due to technical failures.
• I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
• I understand that I may suspend or terminate the use of the telehealth services at any time or for no reason.
• I understand that if I am experiencing a medical emergency, I will be directed to dial 9-1-1 immediately and that the Cycles of Change Recovery Services providers cannot connect me directly to any local emergency services.
• I understand that alternatives to telehealth consultation, such as in-person services, are available to me. In choosing to participate in a telehealth consultation, I understand that some parts of the services involving tests or assessments may be conducted by individuals at my location or a testing facility, at the direction of the Cycles of Change Recovery Services provider.
• I understand that I may expect the anticipated benefits from the use of telehealth in my care but that no results can be guaranteed or assured.
• I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the session other than the Cycles of Change Recovery Services provider to operate the telehealth technologies. I further understand that I will be informed of their presence in the session and thus will have the right to request the following: (1) omit specific details of my psychological health history that are personally sensitive to me; (2) ask unauthorized personnel to leave the telehealth session; and/or (3) terminate the session at any time.
• I understand that Cycles of Change Recovery Services does not provide psychiatric health care and that I will not be given a prescription at all. I understand that if I participate in a session, that I have the right to request a copy of my medical records, which will be provided to me at a reasonable cost of preparation, shipping, and delivery.

I have read this document carefully, understand the risks and benefits of the telehealth session, and have had my questions regarding the session explain d. I hereby give my informed consent to participate in a telehealth session under the terms described herein.

By signing this “INFORMED CONSENT FOR TELEHEALTH SERVICES,” I hereby state that I have read, understood, and agree to the terms of this document.

Patient Name:                                                 

Signature:_                                                                  Date: