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Telemedicine or Technology Assisted Counseling (TAC) Form

  • TELEMEDICINE OR TECHNOLOGY ASSISTED COUNSELING (TAC) CONSENT, POLICIES, & AGREEMENT

    This form is in addition to CenterLife Counseling’s regular “Important Signatures Form” that acknowledges your receipt of CenterLife Counseling’s policies, including, but not limited to, financial obligations and the Notice of Privacy Practices for Protected Health Information commonly known as HIPAA. You must sign both forms in order to participate in Technology Assisted Counseling (TAC) sessions.

    TAC incorporates email, phone, and most often, video counseling. Most insurers that reimburse for TAC, only reimburse for video counseling that is conducted on a HIPAA compliant platform. This may change with positive expansion of coverage for TAC services due to the Coronavirus pandemic. It is your responsibility to check your policy prior to your first TAC session for coverage.

    Prior to engaging in TAC, an assessment will be done to assure that TAC is an appropriate form of counseling for you. The therapist may require that this assessment be conducted at the office, in a face-to-face session. Due to the Coronavirus pandemic the therapist will assess as, best as they can, via the phone or video.

    This is to inform you about what you can expect regarding your participation in TAC.

    Benefits:

    The benefits to TAC are:

    1. Ability to continue services while protecting the health and safety of CenterLife clients, therapists and employees during the impact of the Coronavirus pandemic.
    2. Reduces the overall cost and time of therapy to the client by eliminating the drive to and from an office.
    3. Increased availability of services to homebound clients, clients with limited mobility and clients with compromised health or without convenient transportation options.

    Limitations:

    It is important to note that there are limitations to TAC that can affect the quality of the session(s). These limitations include but are not limited to the following:

    1. Not all issues/concerns/diagnoses are appropriate to be treated by TAC effectively. If this is the case your therapist will recommend other appropriate options.
    2. Not all insurance benefits cover payment for TAC. It is your responsibility to check your policy prior to your first TAC session for coverage. Self-pay can be arranged and is due at time of service.
    3. The therapist cannot see you, your body language, or your non-verbal reactions as clearly as in an office session.
    4. Due to technology limitations the therapist may not hear all of what you are saying and may need to ask you to repeat things.
    5. Technology might fail before or during the TAC session.
    6. Although every effort is made to reduce confidentiality breaches, breaches may occur for various reasons.
    7. To reduce the effect of these limitations, the therapist may ask you to describe how you are feeling, thinking, and/or acting in more detail than they would during a face-to-face session.
    8. You may also feel that you need to describe your feelings, thoughts, and/or actions in more detail than you would during a face-to-face session.

    Logistics:

    When your therapist provides Technology Assisted Counseling sessions, you will be contacted at your scheduled time by email, providing you with a link for the secure and HIPAA compliant video session. The therapist expects that you are available at the scheduled time and are prepared, focused and engaged in the session. The therapist will be providing your session from a private location where they are the only person in the room. You also need to be in a private location where you can speak openly without being overheard or interrupted by others to protect your own confidentiality. If you choose to be in a place where there are people or others that can hear you, the therapist cannot be responsible for protecting your confidentiality. Every effort MUST be made on your part to protect your own confidentiality. One suggestion is to wear a headset to increase confidentiality and also increase the sound quality of the session. Please make sure you reduce all possibilities of interruptions for the duration of the scheduled appointment.

    Please know that per best practices and ethical guidelines, the therapist can only practice in the state(s) that they are licensed in. That means wherever you reside the therapist must be licensed by that state to practice behavioral health therapy. Therefore, please understand that the Technology Assisted Counseling with CenterLife therapists at this time, can only occur in the state of Minnesota. The therapist is accountable and governed by the ethical and legal guidelines prescribed by the state of licensure and residence. Therefore, you agree to inform the therapist if your therapy location has changed or if you have relocated to a different state.

    Connection Loss During Video Sessions: If there is a loss of connection during a video session, the therapist will call you to troubleshoot the reason connection was lost. If the therapist cannot reach you, they will remain available to you during the entire course of the scheduled session. Should you contact the therapist and there is time left in your session, it can continue. If the reason for a connection loss i.e. technology, battery dying, bad reception, etc. occurs on your part, you will still be charged for the entire session. If the loss of connection is a result of something on the therapist’s end, an alternate time to complete the remaining minutes of the session can be arranged.

    Connection Loss During Phone Sessions: If we are using the phone and lose the phone connection during our session, the therapist will call you back immediately. If we are unable to reach each other due to technological issues, the therapist will attempt to call you 2 times. If they cannot reach you, the therapist will remain available to you during the entire course of the scheduled session. Should you contact the therapist back and there is time left in the session, it can continue. If the reason for a connection loss i.e. technology, your phone battery dying, bad reception, etc. occurs on your part, you will still be charged for the entire session. If the loss for connection is a result of something on the therapist end, they will call you from an alternate number. The number may show up as restricted or blocked; please be sure to pick it up.

    Recording of Sessions: Please note that recording, screenshots, etc. of any kind of any session is not permitted and are grounds for termination of the client-therapist relationship.

    Payment for Services: My signature below indicates that I have been provided a copy of CenterLife Counseling’s Financial Policy. I acknowledge that I am responsible for any payments not billable and/or covered by insurance. I acknowledge that I have called my insurance provider to verify payment of Telemedicine Behavioral Health Services. I have made payment arrangements with a credit/debit card on file and/or other payment options made available to me for services rendered by CenterLife Counseling. In compliance with health insurance contracts, CenterLife Counseling cannot waive co-pays or co-insurance amounts. It is your responsibility to check your policy for coverage prior to your first TAC session.

    Cancellation Policy: If you must cancel or reschedule an appointment, 24-hour advance notice is required, otherwise you will be held financially responsible. Should you cancel or miss an appointment with notification less than 24 hours this will result in a charge of $75.00 for your missed appointment. If clients have more than two cancellations during the course of treatment/therapy the therapist and client may address the need for ongoing therapy. Video sessions should be treated the same as regular in-office sessions. If you are late getting on the video session, are unable to meet at the scheduled time, your computer is not available or working, you are unable to access a confidential place to talk, or any other variable that would have you not be able to attend the session, please know that you will be charged for the session. Please make the necessary arrangements you need to be available and present for your session with the technology you need ready for use.

    Emergencies and Confidentiality: CenterLife Counseling considers your e-mail and other contact information to be confidential. We will not disclose or sell any of your contact information to outside parties or entities.

    If a situation occurs where the therapist and you get disconnected and you are in crisis, you agree to call 911, go to your local emergency room immediately or contact the National Suicide Hotline at 800-784-2433.

    If the therapist has concerns about your safety at any time during a video session, the therapist will need to break confidentiality by calling 911 and providing your location and/or calling your emergency contact immediately. Please note that all confidentiality exceptions still apply during video sessions.

    Exceptions to Confidentiality: All CenterLife Counseling employees and Mental Health Professionals have an obligation to respect your right to confidentiality for the information you share within the clinical setting. Confidentiality is governed by federal law (HIPAA) and by state law. The following is a list of situations in which you may lose your right to confidentiality.

    • We are obligated to report any maltreatment of minors and vulnerable adults. This includes physical and sexual abuse and neglect.
    • We are obligated to report any prenatal exposure to controlled substances.
    • We are obligated to report any serious harm you intend to inflict on yourself or another.
    • We are obligated to share information, if directed by a Court Order, to conform to state or federal laws, rules, or regulations.
    • We are obligated to share information with licensing boards, which is pertinent to a disciplinary proceeding involving a licensed provider.
    • In order to receive payment from your insurance carrier, we are obligated to provide them with the records they request to determine medical necessity for payment of services.

    If you are a minor, you have a limited right to privacy in that your parents/guardians may have access to your records. However, if the therapist believes that sharing information will be harmful to you, confidentiality will be maintained to the limits of the law.

    There are instances in which other individuals associated with CenterLife have duties that require access to information about you for billing, case consultations, and bookkeeping purposes. All employees and/or contracted workers sign a confidentiality agreement and are obligated to protect your confidentiality according to the federal and state laws.

    CenterLife Counseling Mental Health Professionals meet for case consultation with the other Mental Health Professionals at CenterLife Counseling. During those meetings, your case may be reviewed. Mental Health Professionals seeing members of the same family or significant others may discuss your case and request that you sign a Release of Information. If you have questions or concerns about this, please speak to your therapist.

  • (the email address that you want the secure session link sent to)
  • Emergency contact for you.
    Please list the person’s first and last name, relationship and phone number(s) of your emergency contact:
  • Please provide the address at which you will most often be present for your video sessions, the number to your local police department, including area code in which you are located during the time of the session, and the county of where the session will take place. Your therapist will ask you at the beginning of each session the address of the location you are currently at for the session.
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