Telehealth Consent Form

I, ___________ [Name of Patient/Client], hereby consent to engage in Telehealth with Tari Tooke, LMFT #47616. I understand that Telehealth is a mode of delivering health care services, including psychotherapy and psychological consultation, via communication technologies (e.g., Internet or phone) to facilitate consultation, diagnosis, treatment, education, care management, and self‑management of a patient’s mental health and wellness.

By signing this form (or clicking the Send Telehealth Consent button), I understand and agree to the following:

1. I have a right to confidentiality with regard to my treatment and related communications via Telehealth under the same laws that protect the confidentiality of my treatment information during in‑person psychotherapy or consultation. The same mandatory and permissive exceptions to confidentiality outlined in this Telehealth Consent Form, which is the informed consent provided on my therapist’s website, also apply to my Telehealth services. I understand that my therapist may determine, at their professional discretion, to end services if it is clinically, ethically, or otherwise appropriate to do so. In such cases, my therapist will make reasonable efforts to provide referrals for continuity of care, which may include providers on my insurance panel, 211, Rula, Lucet, psychologytoday.com, or other appropriate resources for therapy or consultation services. I understand that it is my responsibility to contact my insurance panel directly to obtain information about in‑network providers.
2. I understand that there are risks associated with participating in Telehealth including, but not limited to, the possibility, despite reasonable efforts and safeguards on the part of my therapist, that my psychotherapy or consultation sessions and transmission of my treatment information could be disrupted or distorted by technical failures and/or interrupted or accessed by unauthorized persons, and that the electronic storage of my treatment information could be accessed by unauthorized persons.
3. I understand that miscommunication between myself and my therapist may occur via Telehealth.
4. I understand that there is a risk of being overheard by persons near me and that I am responsible for using a location that is private and free from distractions or intrusions.
5. I understand that at the beginning of each Telehealth session my therapist is required to verify my full name and current location.
6. I understand that in some instances Telehealth may not be as effective or provide the same results as in‑person therapy. I understand that if my therapist believes I would be better served by in‑person therapy, my therapist will discuss this with me and refer me to in‑person services as needed. If such services are not possible because of distance or hardship, I will be referred to other therapists who can provide such services.
7. I understand that while Telehealth has been found to be effective in treating a wide range of mental and emotional issues, there is no guarantee that Telehealth is effective for all individuals. Therefore, I understand that while I may benefit from Telehealth, results cannot be guaranteed or assured.
8. I understand that some Telehealth platforms allow for video or audio recordings and that neither I nor my therapist may record the sessions without the other party’s written permission.
9. I have discussed telehealth fees with my therapist and agree to them. For insurance, we may bill my plan on a case‑by‑case basis, and I will pay any portion that is my responsibility, such as co‑pays or charges from denied claims. I understand that pro bono services may also be offered on a case‑by‑case basis.
10. I understand that my therapist will make reasonable efforts to ascertain and provide me with emergency resources in my geographic area. I further understand that my therapist may not be able to assist me in an emergency situation. If I require emergency care, I understand that I may call 911 or proceed to the nearest hospital emergency room for immediate assistance.

I have read and understand the information provided above, have discussed it with my therapist, and understand that I have the right to have all my questions regarding this information answered to my satisfaction.

[For conjoint or family therapy, patients may sign individual consent forms or sign the same form.]

Electronic Consent (E‑Consent) Acknowledgment: By submitting this form electronically, I confirm I have read and understand the Telehealth Consent Form and agree to receive therapy/consultation via telehealth from Tari Tooke, LMFT #47616. I understand that my electronic submission has the same legal effect as my signature.

For Recordkeeping Purposes — Provider Use Only (not required for client to sign if e‑consent or verbal consent is obtained) 

Consent Type: ☐ Electronic (submitted online)   ☐ Verbal (confirmed in session)  

Date Consent Obtained: ____/____/____

Patient’s/Client's Signature / Date (if applicable): __________________________     ____/____/____

Patient’s/Client's Printed Name: __________________________

Verbal Consent Obtained for (Provider Use Only):  __________________________ [Name of Patient/Client]. Therapist reviewed the Telehealth Consent Form with Patient/Client. Patient/Client understands and agrees to the above advisements, and has verbally consented to receiving psychotherapy and/or psychological consultation services from Tari Tooke, LMFT #47616 via Telehealth.

Therapist’s Signature / Date: __________________________     ____/____/____