I hereby consent to engage in telemedicine (e.g., internet, email, or telephone- base therapy) with Adult Youth Services, LLC., through Thera-Link as the main mode of psychotherapy treatment. I understand that telemedicine's includes the practice of health care delivery, including mental health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video and or data communications. I understand that telemedicine also involves the communication of my medical/mental health information, both orally and visually, to other health care practitioners.

I understand that I have the following rights with respect to telemedicine:

I have the right to withhold or withdraw consent at any without affecting my right to future care or treatment or risking the loss or withdraw of any program benefits to which I would otherwise be entitled.

The laws that protect the confidentiality of medical information also apply to telemedicine. As such, I understand that the information disclosed by me during my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality including but not limited to, reporting child, elder and other vulnerable populations; expressed threats of violence toward ascertainable victim; and where I make my mental or emotional state of issue in a legal proceeding. (See also HIPPA Notice of Privacy Practice forms, provided tome for more details of confidentiality and other issues)

I also understand that there are risks and consequences form telemedicine. These may include, but are not limited to the possibility, despite reasonable efforts on the part of my psychotherapist; that; the transmission of my medical information could be disrupted or distorted by technical failures; the transmissions of medical information could be interrupted by unauthorized persons; and or misunderstandings can more easily occur, especially when care is delivered in an asynchronous manner.

In addition, I understand that telemedicine-base services and care may not yield the same results as complete as face-to-face service. I also understand that if when COVID-19 has run its course, or the state rescind the order of telemedicine that I shall return to face-to-face therapy. Finally, I understand that there are potential risks and benefits associated with any form of psychotherapy and that, despite my efforts and the efforts of my psychotherapist, my condition may not improve and in some cases may even get worse.

I understand that I may benefit from telemedicine, but results cannot be guaranteed or assured. The benefits of telemedicine may include but are not limited to finding a greater ability to express thoughts and emotions; transportation and travel difficulties are avoided; time constraints are minimized; and there may be a greater opportunity to prepare in advance for therapy sessions, eliminated the spread or potential spread of infectious diseases.

I accept that Adult Youth Services, LLC/Thera-Link does not provide emergency services.

I understand that I am responsible for providing the necessary computer, telecommunications equipment and internet access for telemedicine sessions, the information security on your computer and related devices, arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for your session.

I understand confidentiality of emails cannot be guaranteed, you are discouraged from disclosing confidential or sensitive information by these methods.

Commitment: to weekly attendance. Clients are expected to attend therapy/education on a weekly basis and to make every reasonable effort to avoid absences.

Cancellation Policy: It is required a minimum of 24 hours' notice (1 business day) for cancellations. Do not assume I received your message until you hear back from an administrative staff or myself. If you do not contact the agency in the appropriate time and it is considered a no show you will be responsible for the $10.00 fee.

I understand that payment for telemedicine sessions may be difficult to obtain, but you are responsible to pay in full for any sessions that your probation officer does not cover in the form of a voucher.

Acknowledgment: By signing below, you acknowledge that

I have read and understand the information provided above, which has also been explained to me verbally. I have discussed it with my psychotherapist, or the administrative staff and all my questions has been answered to my satisfaction.