To Reach out for Telehealth Services:

Please review the content below.

Please review and prepare the digital form below, mark the checkboxes to acknowledge the requirement.


The purpose of this acknowledgment is to obtain your consent to participate in a telehealth service delivery in connection with counseling services. Telehealth is the delivery of behavioral health services using interactive technologies (use of audio, video, or other electronic communications) between a clinician and a client who are not in the same physical location.

I agree that when I receive telehealth services, I will be located within the state of Ohio. I understand that my clinician is not able to provide clinical services when I may be located outside of state lines.


During the telehealth session, we conduct your counseling session as we would a face to face office-based session. You will be asked a series of questions prior to beginning the session to ensure your safety. The session will take place utilizing telecommunication technology, through Microsoft Teams. Microsoft Teams is a HIPAA secure service. The interactive technologies used in telehealth health incorporate network and software security protocols to protect the confidentiality of client information transmitted via any electronic channel. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption. No video, audio, and/or photo recordings will occur during your session. Microsoft Teams chat will be disabled.


I understand that I must pay for services prior to receiving services if my insurance does not cover my session or I have a co-payment. I will make arrangements to pay for services prior to my appointment either by credit card or in person.


Telehealth health services rely on technology, which allows for greater convenience in service delivery. There are risks in transmitting information over technology that include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties. I understand if for some reason I am disconnected due to loss of connectivity or service, I can contact my clinician via phone at 740-687-0042.


If a need for direct, in-person services arises, it is my responsibility to contact resources in my area, such as my local crisis line (2-1-1) or to contact the agency to schedule a face to face appointment with my clinician or my primary care physician if my clinician is unavailable. I understand that an opening may not be immediately available in the office. I understand that if I am in immediate need of care, I should call 9-1-1 or go to my nearest emergency room.


All existing laws regarding your access to mental health information and copies of your mental health records apply to this telehealth health sessions.


Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with telehealth health sessions, and all existing confidentiality protections under federal and Ohio state law apply to information disclosed during these telehealth health sessions. To ensure your privacy and confidentiality, please participate in the session in a private space that is free from distractions and other parties.


You may withhold or withdraw consent to the telehealth health services at any time without affecting your right to future care, treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.


You have been advised of all the potential risks, consequences, and benefits of telehealth. Your clinician has discussed the information provided above with you. You have had the opportunity to ask questions about the information presented on this form and the telehealth services. All your questions have been answered, and you understand the written information provided above.


My clinician and I will regularly reassess the appropriateness of continuing to deliver services to me through the use of the technologies we have agreed upon today, and modify our plan as needed. I understand that I will be required to attend face to face sessions in the office at a minimum of one time every 60 days.


At the beginning of each session, I will provide the clinician my full name and date of birth to confirm my identity. I will provide the clinician the address of my location and the phone number I can be contacted at.