Addendum-Consent to Telehealth

I, _____________________________________________, consent to participate in Oviedo Counseling Clinics counseling and/or assessment sessions via telephone or video conferencing (i.e., teletherapy) as described below. 

I understand that Oviedo Counseling Clinic cannot and does not guarantee the privacy or security of any session content or communication conducted via telephone or video conferencing. There is potential that video conferencing sessions or phone calls could be intercepted by others, and I understand that communicating via these mediums is not 100% secure. I will not hold the Oviedo Counseling Clinic and therefore Northland Church or RTS responsible for any breaches of privacy or security that occur during telephone or video conferencing contacts. 

I understand that phone and video conference sessions may be recorded (just as in-person sessions are recorded during in-person sessions at the Oviedo Counseling Clinic), reviewed by clinicians and their supervisors, and deleted in a timely manner. 

I understand that clinicians have been informed that, to preserve client confidentiality, telephone sessions and video conferences should be treated like in-office sessions (e.g., the clinician should be in a completely private location, they should ensure no outside distractions occur to the best of their ability, etc.). I further understand that clinicians have been instructed to obtain information about my location at the start of each teletherapy session in case an emergency situation ensues. 

I understand that teletherapy sessions must be scheduled during Oviedo Counseling Clinic’s business hours, in advance in collaboration with my clinician. I understand my clinician will not be available for on-call or emergency appointments. If I or my family members experience a mental health emergency, I should call 911 or go to my nearest emergency department instead of contacting my clinician. 

I understand that if I or my family member is suspected of being at imminent risk for harming oneself during a teletherapy session, I will be instructed to dial 911 or go immediately to the nearest emergency department. My clinician will be expected to call 911 on behalf of my family member and disclose my address to emergency responders if I do not do so myself when I or my child am judged to be at imminent risk for self harm. Similarly, if my clinician believes I or my child are an imminent danger to someone else, they will notify necessary authorities to ensure everyone’s safety. 

ZOOM is a HIPAA compliant online communication tool that allows for phone calls and face-to-face videoconferencing. For more information about ZOOM security and privacy, I can go to ZOOM requires the use of an internet browser but does not require any software to be downloaded. I understand that if I choose to have a counseling or assessment session using ZOOM, my clinician will email me an invitation with a link embedded in it before our session. I will simply click on the link on my computer or smartphone, or dial in to the phone number provided through the Zoom email, to begin our ZOOM session. I understand I should be in a quiet and completely private room when our ZOOM session is occurring. 

Technological difficulties can occur during the provision of clinical services by phone or videoconferencing. To minimize these technological difficulties, I understand I should: 

● Test all necessary software (e.g., ZOOM) before the scheduled session. 

● Use a hardwired connection (via LAN cable) rather than a wireless connection when possible to increase audio and video quality. 

● Ensure my electronic device is fully charged or plugged in before a scheduled session. 

● Be online at least five minutes prior to the scheduled session. 

● Attempt to reconnect with my clinician immediately if an ongoing teletherapy session is interrupted/disconnected. If reconnection cannot occur, my clinician and I will attempt to reschedule the session through email communication. 

● Consider using headphones as an extra layer of privacy. 

I have been informed of and understand the risks and procedures involved with using teletherapy. I agree to the terms listed above and I hereby voluntarily consent to the use of teletherapy with my provider. I agree that the Oviedo Counseling Clinic and therefore Northland Church and RTS should not be held liable in the event that any outside party passes technology security and discovers personal or confidential information. This consent will last for the duration of the relationship with this clinic unless I explicitly withdraw my consent for teletherapy session – which I am allowed to do at any time and for any reason – and my clinician will work with me to find a suitable alternative. 

I understand that payments are payable to Northland Church through the Northland Church App or website by clicking, click Give, click Give to Missions, click Give Type-Give One Time, Fund Oviedo Counseling Clinic Payment. In the Notes section I will enter my 4 digit Client ID   

It is your choice to decline or accept the option of  “Add 2.2% to contribute to processing costs*”

In our refillable PDF version that will be sent to you by your counselor, please type in your information and email back to your counselor.

 Client Name: Date of Birth: 


Parent/Guardian Name (if applicable):

E-Signature of Client or Parent/Guardian:


Signature of Graduate Intern: 


Contact Me

Check your email for further instructions!