1250 SE Maynard Road, Ste. 204
Cary, NC 27511

Ph: 919-371-4378
Fax 919-300-7943


Telemental Health Services Informed Consent


• You will need access to certain technological services and tools to engage in Telemental Health-based services with your provider • Telemental Health (TMH) has both benefits and risks, which you and your provider will be monitoring as you proceed with your work • It is possible that receiving services by TMH will turn out to be inappropriate for you, and that you and your provider may have to cease work by TMH • You can stop work by TMH at any time without prejudice • You will need to participate in creating an appropriate space for your TMH sessions • You will need to participate in making a plan for managing technology failures, mental health crises, and medical emergencies • Your provider follows security best practices and legal standards in order to protect your health care information, but you will also need to participate in maintaining your own security and privacy.

What is Telemental Health?  

“Telemental Health” (TMH) means, in short, “provision of mental health services with the provider and recipient of services being in separate locations, and the services being delivered over electronic media.” Services delivered via TMH rely on electronic, often Internet-based, technology tools. These tools can include video conferencing software, email, text messaging, virtual environments, specialized mobile health (“mHealth”) apps, and others. • You will need access to Internet service and technological tools needed to use the above-listed tools to engage in TMH work with your provider. • If you have any questions or concerns about the above tools, please address them directly to your provider so you can discuss their risks, benefits, and specific application to your treatment.

Benefits and Risks of Telemental Health: 

Receiving services via TMH allows you to: receive services at times or in places where the service may not otherwise be available; receive services in a fashion that may be more convenient and less prone to delays than in-person meetings; receive services when you are unable to travel to the service provider’s office.

The unique characteristics of TMH media may also help some people make improved progress on health goals that may not have been otherwise achievable without TMH. Receiving services via TMH has the following risks: TMH services can be impacted by technical failures, may introduce risks to your privacy, and may reduce your service provider’s ability to directly intervene in crises or emergencies. Here is a non-exhaustive list of examples: internet connections and cloud services could cease working or become unstable to use. Cloud-based service personnel, IT assistants, and malicious actors (“hackers”) may have the ability to access your private information that is transmitted or stored in the process of TMH-based service delivery. Computer or smartphone hardware can have sudden failures or run out of power, or local power services can go out. These interruptions may disrupt services at important moments, and your provider may be unable to reach you quickly. Your provider may also be unable to help you in-person. There may be additional benefits and risks to TMH services that arise from the lack of in-person contact or presence: the distance between you and your provider at the time of service, and the technological tools used to deliver services. Your provider will assess these potential benefits and risks, sometimes in collaboration with you, as your relationship progresses.

Assessing Telemental Health’s (TMH) Fit for You: 
Although it is well validated by research, service delivery via TMH is not a good fit for every person. Your provider will continuously assess if working via TMH is appropriate for your case. If it is not appropriate, your provider will help you find in-person providers with whom to continue services if one is available. Please talk to your provider if you find the TMH media so difficult to use that it distracts from the services being provided, if the medium causes trouble focusing on your services, or if there are any other reasons why the TMH medium seems to be causing problems in receiving services. Raising your questions or concerns will not, by itself, result in termination of services. Bringing your concerns to your provider is often a part of the process. You also have a right to stop receiving services by TMH at any time without prejudice. If your provider also provides services in-person and you are reasonably able to access the provider’s in-person services, you will not be prevented from accessing those services if you choose to stop using telemental health. The important thing is that as a client you can stop using TMH for services without it endangering your access to in-person services, should they exist and be available.

Your Telemental Health (TMH) Environment:
You will be responsible for creating a safe and confidential space during sessions. You should use a space that is free of other people and distractions. It should also be difficult or impossible for people outside the space to see or hear your interactions with your provider during the session. If you are unsure of how to do this, please ask your provider for assistance.

Our Communication Plan At our First Session:
We will develop a plan for backup communications in case of technology failures and a plan for responding to emergencies and mental health crises. In addition to those plans, your provider has the following policies regarding communications. The best way to contact your provider between sessions is to call by telephone at 919-948-7718 (Main Office), email, or by any means agreed to by you and your Therapist. Your provider will respond to your messages within 24 business hours. Please note that your provider may not respond to communications on weekends or holidays. Your provider may also respond sooner than stated in this policy. That does not mean they will always respond that quickly. Our work is done primarily during your appointed sessions, which will generally occur during business hours. Contact between sessions should be limited to confirming or changing appointment times. You may call the Office with billing/insurance questions. Please note that all messages you exchange with your provider, i.e., emails and text messages, will become a part of your health record. Your provider may coordinate care with one or more of your other providers. Your provider will use reasonable care to ensure that those communications are secure and that they safeguard your privacy.

Our Safety and Emergency Plan: 
As a recipient of TMH-based services, you will need to participate in ensuring your safety during mental health crises, medical emergencies, and sessions that you have with your provider. Your provider will require you to designate an emergency contact. You will need to provide permission for your provider to communicate with this person about your care during emergencies. Your provider will also develop with you a plan for what to do during mental health crises and emergencies, and a plan for how to keep your space safe during sessions. It is important that you engage with your provider in the creation of these plans and that you follow them when you need to.

Your Security and Privacy:
Except where otherwise noted, your provider employs software and hardware tools that adhere to security best practices and applicable legal standards for the purposes of protecting your privacy and ensuring that records of your health care services are not lost or damaged. As with all things in TMH, however, you also have a role to play in maintaining your security. Please use reasonable security protocols to protect the privacy of your own health care information. For example, when communicating with your provider, use devices and service accounts that are protected by unique passwords that only you know. Also, use the secure tools that your provider has supplied for communications.

Your provider:

record video or audio sessions. Associate level Therapists (Interns/newly licensed Therapists) may still be receiving clinical supervision and need to record sessions for supervision purposes.  The recording of sessions will always be discussed ahead of time with you and only be done with your written consent.


Signature Instructions:
Touch Screen: use finger or stylus to sign
Desktop Monitor: use mouse or touchpad to sign

Therapist Name and Signature: