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Telemental Health Informed Consent

Please note that due to "Governor Eric J. Holcomb recent announcement to protect and support Hoosiers during the COVID-19 outbreak; telehealth services for mental health, substance use disorder and prescribing for Medicaid covered services will be expanded. Mental health professionals are permitted to practice via telemedicine." Tides of Life will be temporarily providing telemedicine therapy using technology including but not limited to phone, computer and audio/visual equipment.

The priority is to provide services as quickly as possible to assist clients in maintaining their mental health during this time. Please note, that all efforts are being made to provide services in a confidential manner, but it is not practical to implement all HIPPA regulations at this time as acknowledged and authorized by the Governors order. In addition, the use of technology introduces the risk of data breaches and equipment failure that are beyond the control of Tides of Life and its providers. Telemedicine services will be temporarily provided until the ability to see clients in the office is permitted.

Tides of Life in no way implies that your insurance company or EAP provider will cover services provided via Telemedicine. It is the client's responsibility to contact the company and determine the coverage for this service.

With this in mind, please review and complete the form below to allow Tides of Life to provide services via Telemedicine.


I , (name of client) hereby consent to participate in telemental health with Dorothy Rado LCSW/Tides of Life as part of my psychotherapy. I understand that telemental health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.

I understand the following with respect to telemental health:
  1. I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.
  2. I understand that there are risk and consequences associated with telemental health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
  3. I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
  4. I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telemental health unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).
  5. I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required.
  6. I understand that during a telemental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, the therapist will attempt to call you back. If we are unable to reconnect within ten minutes, please call me at to discuss since we may have to re-schedule.
  7. I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.

Emergency Protocols
I need to know your location in case of an emergency. You agree to inform me of the address where you are at the beginning of each session. I also need a contact person who I may contact on your behalf in a life-threatening emergency only. This person will only be contacted to go to your location or take you to the hospital in the event of an emergency.

In case of an emergency, my location is: and my emergency contact person's name, address, phone:

I have read the information provided above and discussed it with my therapist. I understand the information contained in this form and all of my questions have been answered to my satisfaction.

By checking this box and entering my name below I agree that I understand all of the above.