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CONSENT FOR TELETHERAPY CONSULTATION

  1. I understand that my therapist wishes me to engage in a teletherapy consultation with Jimini Health Psychotherapy, P.C. (“Jimini Health”).
     

  2. I understand that Jimini Health only provides virtual teletherapy services and is not intended as a substitute for routine or ongoing medical care or advice for acute or chronic conditions or illnesses.
     

  3. My therapist explained to me how the teletherapy visit using video conferencing technology, as well as messaging-based communication will not be the same as a direct client/therapist visit due to the fact that I will not be in the same room as my therapist.
     

  4. I understand that a teletherapy consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
     

  5. I have fully disclosed to Jimini Health Group all historical, current, and/or ongoing health conditions, impairments, illnesses, or diseases that may impact my care with my  therapist.
     

  6. I have represented to Jimini Health Group my current state of residence and provided a corresponding photo identification. I further represent that this is the location where I will receive my teletherapy services.
     

  7. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.
     

  8. I further understand that I will be primarily communicating with my therapist via in-app messaging, using a third party secure platform. In connection with utilizing this platform, I acknowledge and understand that I will need to “opt in” to receive SMS text messages from Jimini Health and that message and data rates may apply. I also understand that message frequency varies, and that I may text STOP at any time to opt out of communicating with Jimini Health via text message.
     

  9. If we are disconnected during the telehealth consultation, my therapist will call me on the phone, and I hereby authorize such communication.
     

  10. I understand that my therapist or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
     

  11. I understand that Jimini Health Group does not provide urgent or emergency services and that telehealth should not be used in the event I have an urgent or emergent health need. In the event of an emergency, I will use a phone to call 911.
     

  12. I have had a direct conversation with my therapist, during which I had the opportunity to ask questions in regard to the teletherapy services. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
     

  13. To maintain confidentiality I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.  I understand that Jimini Health Group is not responsible for breaches of confidentiality caused by my disclosure of the appointment link or otherwise caused by an independent third party in connection with the teletherapy services.
     

  14. I understand and agree that Jimini Health Group may contact me using automated calls, emails and/or text messaging sent to my landline and/or mobile device. These communications may notify me of preventative care, treatment recommendations, outstanding balances, or any other communications from Jimini Health Group. I understand that I may opt-out of receiving all such communications from Jimini Health Group by notifying Jimini Health Group.
     

By signing this form, I certify: That I have read or had this form read and/or had this form explained to me. That I fully understand its contents including the risks and benefits of the procedure(s). That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

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