Of Sound Mind LLC
www.ofsoundsmind.com
Teletherapy Declaration and Informed Consent
TO CLIENTS
Licensed mental health professionals are required by their licensing boards to provide you, the client, with certain basic information. You have already received and signed the basic Declaration of Practices and Procedures from your therapist. This Teletherapy Policy & Procedure document describes certain important aspects of therapy unique to teletherapy. Please review this information carefully and discuss any questions you have before signing below.
By signing this form, you are not making a commitment to continue teletherapy as a permanent modality, but you will have the option to do so should you and your therapist agree it is in your best interest.
QUALIFICATIONS OF CLINICIAN
I have completed live telehealth care training in addition to my professional qualifications as a clinician. This training covered the Law and Ethics and Clinical Skills specifically related to telehealth care. I will continue to receive at least three hours of continuing education in tele-mental health every two years. All teletherapy sessions will be conducted through www.ofsoundsmind.com, which is encrypted to federal standards.
SCHEDULING AND STRUCTURE OF TELETHERAPY
Counseling sessions will be scheduled in 15, 30, 45, and 60-minute increments, unless you and your therapist agree on a different schedule. The next session will typically be scheduled at the end of the current session unless otherwise agreed upon. The structure of sessions will depend on the treatment plan and interventions being used.
ETHICAL AND LEGAL RIGHTS RELATED TO TELETHERAPY
Your therapist will conduct teletherapy only within the state of Louisiana unless she specifically seeks and obtains licensure in another state. If you relocate to another state, your therapist’s ability to continue providing teletherapy will depend on her decision to seek licensure in that state.
RESPONSIBILITIES OF THE CLIENT
All clients should:
Be appropriately dressed during sessions.
Avoid using alcohol, drugs, or other mind-altering substances prior to sessions.
Be located in a safe and private area appropriate for teletherapy.
Ensure a location with stable internet capability.
Clients should NOT:
Record sessions without first obtaining permission from your therapist.
Allow others to be present during sessions unless discussed and agreed upon with your therapist.
Engage in other activities (e.g., texting, driving) during the session.
POTENTIAL COUNSELING RISKS
Using technology for teletherapy involves some inherent risks. It is possible that information may be intercepted, forwarded, stored, or altered without authorization. While best practices are in place to protect your security and privacy, complete security cannot be guaranteed.
To protect your privacy:
Review the privacy policies of any device or application you use for teletherapy.
Be aware that others (e.g., family, friends, employers) or unauthorized individuals may access your device.
If you have questions about privacy measures, please contact me for guidance.
POTENTIAL LIMITATIONS OF TELETHERAPY
Teletherapy is an alternative form of counseling and should not be viewed as a substitute for prescribed medications or other medical interventions. By signing this document, you acknowledge the following:
Teletherapy may not be suitable in cases of crisis, acute psychosis, or suicidal/homicidal thoughts.
Misunderstandings may occur due to a lack of visual and/or audio cues.
Technological disruptions may impact the quality of sessions.
It is your responsibility to verify that your insurance policy covers telemental health counseling.
EMERGENCY SITUATIONS
The following guidelines are necessary for your safety and must be agreed to:
You will inform your therapist of your physical location during sessions and notify her if this location changes.
During the first teletherapy session, you will provide your therapist with the name and contact information of an individual who can be reached in case of an emergency. You will also sign a release of information for this contact.
You will provide information about the nearest emergency services to your location (e.g., emergency room, police station, or fire station).
In the event of an emergency, your therapist may coordinate with your emergency contact and, if necessary, request that they call 911 or transport you to a hospital.
If you need to contact your therapist between sessions, please call or text and leave a message. Your therapist does not provide 24-hour emergency services. For emergencies after hours, contact your nearest emergency room.
BACKUP PLAN IN CASE OF TECHNOLOGY FAILURE
A phone will serve as the backup option in case of technological failure. Please ensure you have a phone available and provide your therapist with your phone number.
If the video session is disconnected, end the session and attempt to reconnect. If reconnection is not possible within five minutes, call your therapist at the provided number. If your therapist does not hear from you within five minutes, she will attempt to contact you at the provided number.
CONSENT TO TELETHERAPY TREATMENT
I have read and understand this Declaration of Telehealth Policies and Procedures. My signature below indicates my informed consent to services provided by Dr. Mirvat Addi via teletherapy.