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Virtual Visits Consent

During this Coronavirus emergency, Blue Sky Counseling Services is now providing on-line virtual therapy with Virtual Visits.  If you wish to take advantage of these opportunities, please let Joanne know of your interest and read and sign the following consent form.

Definition of Virtual Visits - Virtual Visits (commonly known as "Telehealth") involves the use of electronic communications to enable Blue Sky Counseling Services, PLLC's to connect with individuals using interactive video and audio communications. 
Virtual Visits allows me to diagnose, consult, treat and educate using interactive audio and video communication.  I hereby consent to participating in therapy via a HIPAA compliant video conferencing platform, Google Hangouts Meet or a combination of face-to-face therapy and Virtual Visits.

I understand I have the following rights under this agreement: 
I have a right to confidentiality with Virtual Visits under the same laws that protect the confidentiality of my medical information for in-person therapy. Any information disclosed by me during the course of my therapy, therefore, is generally confidential. 
There are, by law, exceptions to confidentiality, including mandatory reporting of child, elder, and dependent adult abuse and any threats of violence I may make towards a reasonably identifiable person. I also understand that if I am in such mental or emotional condition to be a danger to myself or others, Joanne has the right to break confidentiality to prevent the threatened danger. Further, I understand that the dissemination of any personally identifiable images or information from the Virtual Visits interaction to any other entities shall not occur without my written consent. 
I understand that while therapeutic treatment of all kinds has been found to be effective in treating a wide range of mental disorders, personal and relational issues, there is no guarantee that all treatment of all clients will be effective. Thus, I understand that while I may benefit from Virtual Visits, results cannot be guaranteed or assured. 
I further understand that there are risks unique and specific to Virtual Visits, including but not limited to, the possibility that our therapy sessions or other communication by my therapist to others regarding my treatment could be disrupted or distorted by technical failures or could be interrupted or could be accessed by unauthorized persons. In addition, I understand that Virtual Visits treatment is different from in-person therapy and that if Joanne believes I would be better served by another form of therapeutic services, such as in-person treatment, I may offer this or I may be referred to a therapist in my geographic area that can provide such services. 

I have read and understand the information provided above. I have the right to discuss any of this information with Joanne and to have any questions I may have regarding my treatment answered to my satisfaction. 
I further attest that since I have chosen this form of communication I have been advised that it may not be covered by my insurance company and that I am responsible for any fees incurred during therapy which incorporates telecommunication. 
I understand that I may revoke this consent at any time by giving written notice. I may specify the date, event, or condition on which this consent expires. If none is stated, and if no prior notice of revocation is received, this consent will expire one year after the date it was initiated.

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