I hereby consent to engage in TeleHealth with Psychological Counseling Services. TeleHealth is a form of counseling service provided via telephone/video conferencing. I understand that TeleHealth involves the communication of my mental/medical health information, both orally and/or visually.
TeleHealth has the same purpose or intention as counseling treatment sessions that are conducted in person. However, due to the nature of the technology used, I understand that TeleHealth may be experienced somewhat differently than face-to-face counseling sessions. It is important to be aware that TeleHealth may or may not be as effective as in-person counseling and your counselor will need to evaluate if TeleHealth is an effective form of treatment for each client.
Client’s Rights, Risks and Responsibilities
1. The client must reside in California when all TeleHealth services are provided.
2. The client has the right to withdraw consent for use of TeleHealth services at any time.
3. The laws that protect the confidentiality of my treatment also apply to TeleHealth. Also, the mandatory and permissive exceptions to confidentiality that apply in face-to-face counseling, also apply to TeleHealth.
4. The client understands that there are risks and consequences of participating in TeleHealth, including, but not limited to, the possibility, that the transmission of my information/session could be disrupted or distorted by technical failures; that my information/session could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
5. The client understands that there may be a benefit in using TeleHealth, but that results cannot be guaranteed or assured.
6. The client understands that emergency services are not provided when using TeleHealth, but in the event of an emergency, your counselor will provide information on resources in your area.
7. The client understands that there is a risk of being overheard by anyone near them if not in a private area while participating in TeleHealth. TeleHealth services will not be provided when the client is in a moving vehicle. The client is responsible for (A) providing the necessary computer, telecommunications equipment and internet access for all TeleHealth sessions, and (B) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for all TeleHealth sessions.
The person you indicated as your Emergency Contact at the time of your intake will only be contact in an
Please know that e-mail communication is NOT considered a confidential medium of communication.
Therefore, it is preferable that you communicate with your counselor or with Psychological Counseling
Services by phone or in person.
Notice to Clients
The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of (marriage and family therapists, licensed educational psychologists, clinical social workers, or professional clinical counselors). You may contact the board online at www.bbs.ca.gov, or by calling (916) 574-7830.
If you have needs of an urgent nature after hours, you may contact 911 or
the Campus Safety at 661-222-2702.