TELE-MENTAL HEALTH INFORMED CONSENT 

MLL LICENSED CLINICAL SOCIAL WORK SERVICES, PLLC
MARILYN L. LAVES, LCSW-R

This document is intended to review the general policies, procedures and conditions for obtaining tele-mental health services from Marilyn Laves, LCSW-R and to obtain your informed consent for the provision and conditions under which the services are provided. 

1. Access – Tele-mental health services will be scheduled and performed only during regular business hours. I will need to have your local geographic address at the beginning of each session. In between sessions, you may email or text regarding scheduling or billing. Email or text will not be used for tele-mental health services, or to exchange clinical data. Your virtual session time is reserved solely for you. Please treat your session as you would a normal session, i.e. be on time, give 24 hour cancellation notice, etc.   

2. Privacy/Security – I will always endeavor to use secure software. However, you are aware that at this time, it is virtually impossible to ensure confidentiality of electronically exchanged material, whether through video conferencing, email, texting, or phone calls. You are aware of privacy risks inherent in using this software, and by using tele-mental health services agree to assume such risks.  Please have a secure internet connection, not a public/free wifi.  Please also have a quiet, private space free of distractions.   

3. Risks – There are potential benefits and risks to virtual sessions.  Benefits include ease of access to care.  Risks include communication problems, limited visibility, privacy concerns as stated above, interruptions from external environmental factors, possible delayed response in emergency, and others. You agree to accept these risks.   

4. Backup plan:  We agree to use another video/audio service if the video-platform fails.  In the event of system failure, please be sure I have your phone number and you have mine so that the session can continue via telephone.  

5. Emergencies – Tele-mental health services will not be offered, or cease to be offered, if I determine that you need a different mode of care.  If an emergency were to occur, you will need to call 911 at your location. If you need to change your level of support at some point during the time tele-mental health services are being provided, I will help you find an appropriate resource.  

6. Payment – Payments or co-payments are due at the time services are rendered.  If you do not show up for or cancel your scheduled tele-mental health appointment with at least 24 hours notice, full payment**  for the missed session is expected. 

** If you have Cigna, you are responsible for the insurance’s allowable rate and not just your co-pay.