TeleHealth Informed Consent

Consent to Treat via Online or Web-based Delivery

You are invited to participate in counseling with your Provider at Family Counseling Associates (FCA) via a web-based portal. In order to participate, you must be at least 18 years of age.

Please take time to read this entire form and ask questions before deciding whether to take part in counseling through a web-based option.

 The purpose of offering a web-based delivery of counseling is for clients who cannot reasonably attend sessions in the office and who can access counseling through a secure, HIPAA compliant website, provided by FCA. Sessions delivered via a web-based platform may be an option that your therapist deems appropriate for your care in certain circumstances.

If your therapist determines that web-based treatment is appropriate for you, your therapist will discuss web-based treatment options with you. Reasons for not being able attend sessions but seeking counseling via web may include:

  • Illness—you are ill but are feeling well enough and wish to take part in a session.
  • Travel—you may travel for work or leisure and still wish to seek counseling services.
  • Other—there may be other situations that prompt the need for web-based treatment, as determined between you and your therapist.

If you decide to take part in online or web-based services, please prepare for your session and set up for the call, including downloading software and testing your equipment. You need to consider and plan for your own confidentiality and privacy as well. Though FCA will offer a HIPAA compliant server, be sure to protect your own privacy in the following ways:

  • Have headphones or another device that only you can hear so others cannot hear the discussion from the Provider
  • Find a quiet, private space
  • Consider how to eliminate background noise
  • Have fast, reliable Internet
  • Most web-based deliveries of counseling include a video option. You can enable or disable the video, but remember to maintain the privacy of your own surroundings and those who may come in and out of the room since the video can be seen by your therapist if you have the video enabled.

Potential Risks

Therapy conducted online may be interrupted due to problems with internet connectivity, hardware, software, equipment, and/or other service issues. Any problems with internet availability or connectivity are outside of the control of the therapist and the therapist makes no guarantee that such services will be available or work as expected. If technical complications occur that prevent or disrupt any scheduled appointment and the session cannot be completed via online video conferencing, you agree to call your therapist or that he/she will call you at a predetermined number.

To minimize the risk of disruptions, please note the following:

  • We could have trouble connecting
    • To minimize this, please offer a phone number for your Provider to call so they can walk you through getting connected or making plans to reschedule
  • We could become disconnected during the online session
    • To minimize this, please offer a phone number for your Provider to call you should you become disconnected so you can plan for next steps.
  • You may need additional support
    • Consider discussing with your Provider what options for support you have in your community or family outside of the web-based, 50 minute counseling session with your Provider.

Personal Information and Confidentiality

Web-based options will be delivered over a HIPAA compliant server and platform. Your case notes and personal information will be confidential and kept on the same electronic health record our Providers use every day at FCA. Your payment information is also secure over our website.

Confidentiality and the limits to confidentiality will not change. Please talk with your Provider about any questions you have about this.

I AGREE TO TAKE FULL RESPONSIBILITY FOR THE SECURITY OF ANY COMMUNICATIONS OR TREATMENT ON MY OWN COMPUTER AND IN MY OWN PHYSICAL LOCATION. I understand I am solely responsible for maintaining the strict confidentiality of my user ID and password and not allow another person to use my user ID to access the Services. I also understand that I am responsible for using this technology in a secure and private location so that others cannot hear my conversation. 


Before agreeing to be seen through a web-based application, be sure that you understand the information provided to you. Please keep a copy of this document for your records. If you have any questions, please contact your Provider.

I voluntarily agree to receive online therapy services for continued care, treatment, or other services and authorize my FCA therapist to provide such care, treatment, or services as are considered necessary and advisable. I understand and agree that I will participate in the planning of my care, treatment, or services and that I may withdraw consent for such care, treatment, or services that I receive at any time. By proceeding with my telemental health session, I give my Informed Consent and acknowledge that I have both read and understood all the terms and information above.

Telehealth eConsent