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Informed Consent for Treatment:

Overview of Services:

I understand that the purpose of treatment is to help reduce symptoms of psychological suffering.  Cognitive based therapies (CBT/ ACT) and psychodynamic principles as well as medication management, if indicated, may be used.  I understand that I may experience an increase in symptoms at the beginning of treatment but that Dr. Thurston will work through these symptoms with me.  I understand that I am expected to actively engage in the therapy in order to receive the most benefit.

I understand that I will be meeting Dr. Thurston via Zoom (videoconferencing software) and not in-person.  I agree to work with Dr. Thurston to establish frequency and duration of meetings. I understand that I will be responsible for providing the videoconferencing equipment (e.g., webcam, microphone and speakers) and installing the equipment onto my home computer prior to the first therapy session.  If for some reason the videoconferencing technology does not work or I have problems, I will call Dr. Thurston for help over the phone. However, I understand that TMHC is unable to provide me help in person. I acknowledge that I may encounter technological difficulties throughout therapy and I agree to work with Dr. Thurston to fix any problems that arise (e.g., dropped calls, frozen images).

I have agreed to treat therapy via videoconferencing software the same way that I would treat in-person therapy.  This agreement includes but is not limited to: appropriate dress (e.g., as if I were being seen in a public clinic), 24 hour cancellation notice, active engagement in therapy (e.g., not checking emails or surfing the web during sessions), etc.  I have agreed that I will place any pets in a separate room prior to the start of each session so that I am not distracted during therapy. I confirm that I will be in a private room during therapy and that I have asked for family and friends not to enter the room while I am in session.  I agree to work with Dr. Thurston in ensuring that my privacy is protected both via videoconferencing and in my home because of the sensitive topics we may discuss during therapy sessions.

I understand that I can reach Dr. Thurston for non-emergencies at (757) 404-6592.  I acknowledge that Dr. Thurston prefers to communicate over the phone and does not use personal e-mail with patients.  Additionally, I understand that I should call 911 in the case of emergency, such as if I am having thoughts of harming myself or others.

Risks and Benefits:

I understand that when engaging in psychological treatment, there may not be benefits to me.  However, I may end up experiencing an improvement in my mental health and overall well-being.

I understand that the use of videoconferencing may have some limits of confidentiality.  Also, I acknowledge that third parties could access information shared via videoconferencing without Dr. Thurston’s or my knowing (e.g., if someone hacks into the computer system or server).  However, Dr. Thurston, TMHC and I have all installed encryption (i.e., software that allows only the intended recipient to view information) to help protect information that is shared via videoconferencing.  All software complies with national and state laws (including HIPAA compliance) to protect information shared via videoconferencing.

I understand that videoconferencing can result in technological difficulties, such as dropped calls, frozen images, pixilated images, lack of sound, or distorted sound.  Dr. Thurston and I have agreed that if the videoconferencing equipment fails during therapy sessions and cannot be fixed in less than 5 minutes, he will call me on my cell phone and we will finish the session over the phone.  I understand that I am responsible for fixing any problems that my internet, computer, or videoconferencing equipment is having and that TMHC will not be able to assist me in person.

Confidentiality:

I understand that Dr. Thurston will keep all of our conversations confidential, but that he must follow mandatory reporting laws.  I understand that if I reveal any information about child or elder abuse, Dr. Thurston will need to report it. I understand that if I reveal any information that I am going to harm myself or others, Dr. Thurston will need to report it.

I understand that only Dr. Thurston will have access to my files.  Dr. Thurston uses Acuity for scheduling and the electronic health record Practice Fusion to maintain files and record encounters.  I understand that I have access to these files and that I am encouraged to log in to my account to ensure information is correct via patientfusion.com.  I understand that Dr. Thurston will provide me a link and access code for this information via e-mail.

I understand that TMHC participates in the Virginia Prescription Monitoring Program and that TMHC may request information regarding my past medications through this service.

Transmission of Patient Information:

I understand that I am not to e-mail any personal information to Dr. Thurston, but instead I will fill out electronic versions of any questionnaires that Dr. Thurston may have for me or use secure messaging through my Patient Fusion account.  I understand that these electronic files are located and saved on Practice Fusion and that only Dr. Thurston can access them.

I recognize that Dr. Thurston will not be audio- or video-recording any of my sessions.  I agree to tell Dr. Thurston if I would like to audio- or video-record my therapy sessions.  However, I agree to not share these audio- or video-recordings online or with the public. Dr. Thurston will be documenting clinical progress notes after each session and I understand that I may access these via Practice Fusion.  I understand that clinical progress notes will include a summary of my treatment sessions, mental status information, diagnosis, and treatment plans.

Emergency Plans and Safety:

Dr. Thurston and I have agreed that if I am in an emergency (e.g., feel like harming myself or others) in-between sessions that I will call 911.  I recognize that because I am in my own home and not in a mental health clinic, Dr. Thurston will not be able to readily assist me in-person if I become particularly distressed during a session.  Therefore, I understand that if I am engaging in a videoconferencing therapy session and I feel particularly distressed, I will tell Dr. Thurston so that he can contact local emergency personnel, if needed.  I have given Dr. Thurston my most recent address so that he can identify the local emergency staff and I understand that he will have this information readily available at all times during sessions. I agree to tell Dr. Thurston if my address should change so that he can update the information and identify different emergency resources, if needed.  I understand that if there is a technological emergency (e.g., videoconferencing failing) that Dr. Thurston will call my cell phone and that if he is unable to contact me after two attempts he may call my alternate contact to confirm my safety.

Termination or Changes in Care:

I understand that all participation in services is voluntary and that I may decide to end care at any time without penalty (or decision affecting future services).  I understand that if Dr. Thurston believes that more intensive services are needed (e.g., inpatient) that we will stop therapy via videoconferencing and make other arrangements.  Dr. Thurston will end care if he believes it is in my best interest (e.g., my symptoms are getting worse or the treatment is harmful). Also, I understand that if I skip more than four sessions without notice, Dr. Thurston may not provide therapy to me any longer and will give me a referral to another provider.

Billing and Insurance:

TMHC currently does not accept insurance, but it is able to provide billing codes that may be submitted to the insurance company.  Should I choose to seek insurance reimbursement I assume full responsibility for the breach in confidentiality that may ensue.  I understand that payment in full is required at the time of scheduling an appointment. If for some reason I cannot process the transaction online, I agree to send a check via postal mail to the office.  I recognize that I will be provided with a printable receipt of payment for my records.

Other Information:

I agree to give Dr. Thurston 24 hours’ notice if I need to cancel or reschedule an appointment.  If I cancel within 24 hours I understand that I will only be reimbursed 50% of the fee. If I fail to provide any notice (no show) I understand that no reimbursement will be made.  I can contact Dr. Thurston at (757) 404-6592 if I need to cancel or reschedule. I can also submit appointment, cancellation and rescheduling requests via my portal at PatientFusion.com.  I understand that I will not be able to schedule additional sessions until all appropriate fees have been paid.

Voluntary:

I am aware that my participation in therapy with Dr. Thurston is voluntary.  I understand that I can end services at any time without penalty and that Dr. Thurston will work with me to provide another referral, if desired.

Patient Consent to Services:

Patient shall defend, hold harmless and indemnify Provider, its agents, contractors and employees from and against any and all claims, suits, liabilities, damages, judgments, costs and expenses, including reasonable attorney fees, which may be imposed upon, or suffered or incurred by, any of them as a result of claims by Patient that arise out of or derive from information lost owing to technical failures related to telemedical services given by Provider or any of its agents or employees to Patient.

I, the undersigned, have read this entire document and have had the opportunity to ask questions.  I acknowledge all content in this document. I understand the limits of confidentiality when using videoconferencing software and when required to report by law.  I recognize that I am responsible for installing video-conferencing software onto my computer and fixing any problems that may arise. I agree to pay at the time of scheduling each session and will mail a check if needed.  I acknowledge that I may end therapy at any time and may refuse to participate in any portions of the therapy.

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Patient signature                        Date

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Patient name (printed)