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Definition of Telehealth
Telehealth involves the use of electronic communications to enable the mental health professionals of Watersedge Counselling to connect with individuals using interactive video and audio communications.
Telehealth includes the practice of mental health care delivery, diagnosis, consultation, treatment, referral to
resources, education, and the transfer of medical and clinical data.
I understand that I have the rights with respect to telehealth:
1. The laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my sessions is generally confidential. However, there are both mandatory and permissive exceptions to
confidentiality, including, but not limited to, reporting child, elder, and dependent adult abuse; expressed threats of violence toward an ascertainable victim; and where I make my mental or
emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities
shall not occur without my written consent.
2. 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.
3. I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the counsellor, that: the transmission of
my personal information could be disrupted or distorted by technical failures, the transmission of
my personal information could be interrupted by unauthorised persons, and/or the electronic
storage of my personal information could be unintentionally lost or accessed by unauthorised persons. Watersedge Counselling utilises secure, encrypted audio/video transmission software to
deliver telehealth.
4. I understand the alternatives to counselling through telehealth as they have been explained to
me, and in choosing to participate in telehealth, I am agreeing to participate using video conferencing technology. I also understand that at my request or at the direction of my counsellor, as the extenuating circumstances surrounding the spread of COVID-19 change,
services will resume as “face-to-face” psychotherapy.
5. I understand that I may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of telehealth in my care, but that no results can be guaranteed or assured.
6. I understand that my express consent is required to forward my personally identifiable information to a third party.
7. I understand that I have a right to access my medical information and copies of my medical records in accordance with the laws pertaining to the state in which I reside.
8. By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 000 or seek help from a hospital or crisis-oriented health care facility in my immediate area.
Payment for Telehealth Services
Watersedge Counseling will follow standard practices of receiving payment at the time of service or the
session rate will be charged during the same calendar week .
Patient Consent to the Use of Telehealth
I have read and understand the information provided above
regarding telehealth, have discussed it with my counselor, and all of my questions have been answered to my
satisfaction. I have read this document carefully and understand the risks and benefits related to the use of
telehealth services and have had my questions regarding the procedure explained. I hereby give my informed
consent to participate in the use of telehealth services for treatment under the terms described herein.
By my signature below, I hereby state that I have read, understood, and agreed to the terms of this document.
