Telehealth Consent

Effective Date: November 14, 2024

Telehealth services enable you to receive care from a licensed provider at Neff Health & Wellness via secure video or audio communication. This document outlines the benefits, risks, and your rights regarding psychotherapy provided via telehealth.

◈ Description of Services Provided

Telehealth services may include assessment, diagnosis, treatment, follow-up care, and patient education. These services are conducted via secure video or audio communication and comply with legal requirements for privacy and data protection.

◈ Benefits of Telehealth

Increased convenience by allowing you to receive care from home.
Timely access to psychological services.
Cost savings.

◈ Risks

Technical issues (e.g., poor connection or equipment failures) may delay or disrupt care.
Rarely, there may be a privacy breach despite our security measures.
Telehealth is not suitable for emergencies. If you experience an emergency, please call 911 or go to the nearest emergency room.
Experiencing uncomfortable emotions like sadness, guilt, anger, anxiety, or frustration when addressing personal challenges.

◈ Limitations Of Services

Telehealth is an additional service and not a replacement for in-person care or your primary physician. Your provider may recommend in-person treatment if deemed more suitable for your needs.
If a specialized therapy outside the therapist’s expertise is needed, they will discuss this with the client and help connect them with another therapist who can provide the appropriate care.

◈ Consent Statement

[Before therapy begins, you will be asked to confirm your understanding of our telehealth policies. The following text is for you to review prior to your first session.]

By checking the box associated with "Informed Consent," you understand and agree to the following:

Right to In-Person Services: You have the option to request in-person services if preferred, and your provider may recommend in-person treatment if they believe it would better serve your needs.
Right to Withdraw Consent: You may withhold or withdraw your consent for telehealth services at any time without affecting your right to future care or treatment.
Privacy and Security: You understand that Neff Health & Wellness will take steps to protect your health information in compliance with federal and state laws, including using secure communication technology. However, you acknowledge that there is a rare risk of a privacy breach due to unforeseen technical failures.
Technical Limitations: You understand that technical issues (e.g., poor connectivity or equipment failures) may impact telehealth services. If a session cannot proceed due to technical difficulties, you may reschedule or be referred for in-person care if necessary.
Emergency Limitations: You acknowledge that telehealth is not intended for emergency situations. In the case of a medical or mental health emergency, you should call 911 or go to the nearest emergency room immediately.
Consent to Share Health Information for Operational Purposes: You understand that your healthcare information may be shared with authorized personnel for scheduling, billing, or technical support purposes. You have the right to request that specific details of your health information be withheld from any non-clinical personnel present.
Presence of Non-Clinical Personnel: You may request that non-clinical personnel (e.g., technical support staff) leave the telehealth session, and you may omit any details of your health history that are personally sensitive to you.
Right to Medical Records: You have the right to request a copy of your medical records at any time, which will be provided at a reasonable cost for preparation, shipping, and delivery.
No Guarantee of Outcomes: You acknowledge that, while telehealth may provide benefits, specific outcomes or results cannot be guaranteed.

For any questions, please contact Admin@NeffHW.com.

This consent form was created in compliance with Mich. Admin. Code R. 330.7003