Tele-Mental Health Services Informed Consent

Understand that tele-mental health services are the use of electronic information and communication technologies by a mental health care provider to deliver mental health services when the client is at a different location or site than the provider. At CCWC, tele-mental health services will take place in the form of audio counseling via telephone and/or video conferencing. Email and text messages will not be included as a means of communication.

While in-person mental health treatment is the preferred method for providing services, tele-mental health services are available to reduce barriers to treatment. Tele-mental health services are beneficial in order to increase access to services and allow for your treatment to continue in the event you are not able to attend in-person appointments. Please be aware that tele-mental health may be a slower process than in-person services and that progress will be reviewed and evaluated.

As a client, you have the right to withhold or withdraw consent from tele-mental health without affecting additional programs at CCWC or future treatment at CCWC. The confidentiality laws that apply to in-person services also apply to tele-mental health, including mandated reporting of child, elder, and animal abuse and the right to break confidentiality should your provider feel you are at risk of harming yourself or others.

Please understand that there are risks involved regarding tele-mental health, including the risk of disrupted or distorted calls due to technical failures. Understand that landlines and cell phones may not be completely secure or confidential. There is a possibility that someone could overhear or intercept the conversation. Those that have access to your cell phone and landline number, as well as your cell phone and landline bill may be able to see who initiated the call, how long the call took place, and where each party was located during the conversation.

Your conversation during tele-mental health sessions will become part of your electronic health record and will be referred to as Protected Health Information (PHI).

Understand that CCWC may not provide tele-mental health services if you are outside the state of Ohio.

Understand that it is your responsibility to choose a secure location during the tele-mental health appointment and please be aware of your surroundings, knowing that individuals could overhear your conversation. Also understand that you are not to record your tele-mental health appointment.

Understand our ability to provide telehealth services is based on approval of various funding, legal, and licensure bodies. If any changes were to arise regarding the availability of telehealth, you will be notified and reasonable changes to treatment will be recommended.

If you are in need of emergency mental health services, or in the event that CCWC is closed and you are in need of mental health services, please contact your local ER to arrange safe travel for assessment, call 911, call CONTACT at 419-562-9010, or call Pathways at (800)544-1601. Please understand that if you are experiencing suicidal, homicidal, and/or psychotic symptoms and a higher level of care is needed, your provider will take the appropriate steps to address this situation, such as conducting a well-being check.

Should you have questions regarding billing and tele-mental health at CCWC, please contact Brittany Massey. Should you have concerns regarding your rights as a client, please contact Lexi Jeffire, LPCC-S, Consumer Rights Officer, to express your concerns or file a grievance.

By stating that you "agree," you are recognizing both the potential benefits and risks associated with tele-mental health services.