PLEASE REVIEW AND COMPLETE THE INFORMED CONSENT FOR TELEHEALTH 

This Informed Consent for Telehealth services contains important information focusing on providing healthcare services using the phone or the Internet. Please read this carefully, and let me know if you have any questions. When you sign this document, it will represent an agreement between Vitalitas Denver, PC and you. As it pertains to this agreement “I“ is understood to be Vitalitas Denver.

Benefits and Risks of Telehealth
Telehealth refers to providing Psychiatric and educational services remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of telehealth is that the patient and clinician can engage in services without being in the same physical location. This can be helpful particularly during the Coronavirus (COVID-19) pandemic in ensuring continuity of care as the patient and clinician likely are in different locations or are otherwise unable to continue to meet in person. It is also more convenient and takes less time. Telehealth, however, requires technical competence on both our parts to be helpful. Although there are benefits of telehealth, there are some differences between in-person treatment and telehealth, as well as some risks. For example:

• • Risks to confidentiality. As telehealth sessions take place outside of your infusion clinic there is potential for other people to overhear sessions if you are not in a private place during the session. On my end, I will take reasonable steps to ensure your privacy. It is important; however, for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other devices. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation.
  • Issues related to technology. There are many ways that technology issues might impact telehealth. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies.
  • Crisis management and intervention. Usually, I will not engage in telehealth with clients who are currently in a crisis situation requiring high levels of support and intervention. We do not have an option of in-person services, but in a crisis situation, you may require a higher level of services. Before engaging in telehealth, we will collect emergency information to address potential crisis situations that may arise during the course of our telehealth work.

Electronic Communications
You may have to have certain computer or cell phone systems to use telepsychology services. You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software to take part in telehealth. For communication between sessions, I only use email communication and text messaging with your permission and only for administrative purposes unless we have made another agreement. This means that email exchanges and text messages with my office should be limited to administrative matters. This includes things like setting and changing appointments, billing matters, and other related issues. You should be aware that I cannot guarantee the confidentiality of any information communicated by email or text despite having and using a HIPAA compliant platform. Therefore, I will not discuss any clinical information by email or text and prefer that you do not either. Also, I do not regularly check my email or texts, and do not respond immediately, therefore, these methods should not be used if there is an emergency.

Treatment is most effective when clinical discussions occur at your regularly scheduled sessions. But if an urgent issue arises, you should feel free to attempt to contact our offices by phone. We will try to return your call within 24 hours except on weekends and holidays. If you are unable to reach us or there is a crisis situation that needs attention please dial 911 or contact your primary care providers ( therapist, PCP, Psychiatrist).

Confidentiality
I have a legal and ethical responsibility to make my best efforts to protect all communications that are a part of telehealth services. The nature of electronic communications technologies, however, is such that I cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. I will try to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for telehealth sessions and having passwords to protect the device you use for telehealth).

Appropriateness of Telehealth
During this time, telehealth is the only platform that we are conducting psychiatric evaluations and follow-up visits. If you decide telehealth is not optimal for you, it is important to let me know. We will discuss options of engaging in referrals to another professional in your location who can provide appropriate services.

Emergencies and Technology
Assessing and evaluating threats and other emergencies can be more difficult when conducting telehealth than in traditional in-person treatment. To address some of these difficulties, we will create an emergency plan before engaging in telehealth services if a high risk is identified. I will ask you to identify an emergency contact person who is near your location and who I will contact in the event of a crisis or emergency to assist in addressing the situation. This person should have a signed authorization form allowing me to contact your emergency contact person as needed during such a crisis or emergency. If the session is interrupted for any reason, such as technological connection failure, and you are having an emergency, do not call me back; instead, call 9-1-1, or go to your nearest emergency room.

If the session is interrupted and you are not having an emergency, disconnect from the session and I will wait two (2) minutes and then re-connect you via the telehealth platform on which we agreed to conduct treatment. If I do not connect via the telehealth platform within two (2) minutes, then please feel free to contact the office to inform staff of any need to reschedule.

Fees
The same fee rates will apply for telehealth as in-person therapy. Please discuss any fees with your clinic.

Records
The telehealth sessions shall not be recorded in any way unless agreed to in writing by mutual consent. I will maintain a record of our session, in the same way, I maintain records of in-person sessions in accordance with my policies through the use of electronic medical records. You have a right to get a copy of your medical information as per state law.

Informed Consent
This agreement is only intended to apply to Telehealth services by Vitalitas Denver, and does not apply to any of the terms of your ketamine infusion clinic consent form or your ketamine infusion treatment. Given that this consent is voluntary you may withhold or withdraw your consent from participating in telehealth. Your withdrawal or withholding of consent shall not be taken against you and you are afforded other means of health care services other than telehealth. Your signature below indicates agreement with the terms and conditions of this Telehealth consent form. It signifies your agreement to be seen over telehealth platforms and receive electronic communications as appropriate to initiate and continue treatment.