Tele-Behavioral Health Policy and Agreement

Telehealth Behavioral Health Services Agreement

This Telehealth Behavioral Health Services Agreement ("Agreement") outlines the terms and conditions for accessing and using telehealth behavioral health services provided by Dr. Felisha Jackson ILyas EdD-CI, MSW, BS, LCSW, LICSW-S. By accessing telehealth services, you ("Client") agree to the following terms:

1. Services Provided

The Provider agrees to offer telehealth behavioral health services, including but not limited to individual therapy, assessments, counseling, and other mental health support via secure video, phone calls, or other digital platforms.

2. Technology and Confidentiality

• Technology Requirements: The Client is responsible for ensuring they have the necessary technology and internet connection to participate in telehealth sessions. This includes access to a compatible device, stable internet connection, and appropriate software.

• Confidentiality: Telehealth sessions will be conducted through a secure platform that adheres to privacy and confidentiality standards, including compliance with the Health Insurance Portability and Accountability Act (HIPAA). The Provider will maintain confidentiality of all personal health information shared during sessions, subject to the limitations outlined below.

3. Informed Consent

By accessing telehealth services, the Client acknowledges that they have been informed about:

• The nature of telehealth services and how it differs from in-person therapy.

• The potential risks associated with telehealth, including:

  • Technological Issues: The possibility of technical issues (e.g., poor internet connection, software malfunction, power outages) that could disrupt or delay the session.

  • Privacy and Security: While every effort will be made to ensure confidentiality, there is always a risk associated with electronic communications. Unauthorized access to information or data breaches may occur, despite the use of secure platforms.

  • Limited Non-Verbal Cues: Telehealth services limit the Provider’s ability to fully assess non-verbal cues (such as body language and facial expressions), which may affect the ability to understand certain emotional responses.

  • Effectiveness of Remote Treatment: While telehealth is effective for many clients, it may not be appropriate for all individuals or mental health conditions. In some cases, in-person therapy may be recommended for optimal care.

  • Emergency Situations: Telehealth services are not suitable for emergencies. In cases of crisis or urgent medical needs, immediate in-person care is recommended.

4. Client’s Responsibilities

• The Client agrees to actively engage in the sessions, follow the agreed-upon treatment plan, and communicate openly with the Provider.

• The Client is responsible for creating a private and quiet space to attend telehealth sessions, ensuring confidentiality on their end.

• If the Client is experiencing a crisis or emergency situation, they agree to contact local emergency services or go to the nearest emergency room, as telehealth is not appropriate for urgent care. Therapist will support you in accessing emergency services in the event that crisis occurs during session.

5. Cancellation and No-Show Policy

• The Client agrees to provide at least 24 hours notice if they need to cancel or reschedule an appointment. Failure to do so may result in a cancellation fee.

• If the Client does not attend a scheduled telehealth session and does not provide prior notice, a no-show fee may apply.

6. Emergency Situations

Telehealth services are not suitable for emergencies. If a Client is experiencing a mental health crisis or emergency, they agree to contact emergency services 911 or 988 (National Suicide Crisis Hotline) or go to the nearest emergency room.

7. Termination of Services

• Either the Client or Provider may terminate telehealth services at any time. The Provider may also refer the Client to another healthcare provider if necessary.

• The Client may request a referral or alternative options if they wish to discontinue telehealth services.

8. Payment and Insurance

• The Client agrees to pay for services rendered as per the agreed-upon fees or insurance plan.

• The Client is responsible for understanding their insurance coverage (if applicable) and confirming that telehealth services are covered.

• Payments for telehealth sessions are due before or at the time of the session, and any outstanding balances must be paid as per the Provider's billing policy.

9. Limitations of Telehealth

While telehealth services are convenient and effective, they may not be suitable for all individuals or situations. The Provider reserves the right to determine if telehealth is appropriate for a Client’s care. In some cases, the Provider may recommend in-person sessions or referrals to other healthcare professionals.

10. Risk Acknowledgment

The Client acknowledges and accepts the following risks associated with telehealth services:

• Technological Failures: There may be delays or interruptions due to technical issues, such as poor internet connectivity or software malfunctions.

• Privacy and Security Concerns: Although the Provider uses secure platforms, no communication method is 100% risk-free. There may be potential risks regarding data security and privacy.

• Inability to Assess Non-Verbal Cues: The lack of face-to-face interaction may make it difficult for the Provider to observe non-verbal signals, such as body language or facial expressions, which can limit the Provider’s ability to fully understand emotional states.

• Limited Physical and Emotional Support: Remote therapy may not be suitable for everyone, especially for those with severe symptoms or who need more intensive in-person care.

• Emergency Situations: In the event of a mental health emergency, telehealth is not equipped to offer immediate support. The Client agrees to contact emergency services or visit a local emergency room if necessary.