I hereby consent to engaging in online counseling with Ms. Nisha Jain as part of my psychological support. I understand that “online counseling” includes the practice of health care delivery, consultation, treatment, transfer of data, and education using interactive audio, video, or data communications. I understand that it also involves the communication of my medical/mental information, both orally and visually, to other health care practitioners if needed.

I understand that I have the following rights with respect to online counseling:

1. The laws that protect the confidentiality of my medical information also apply to online counseling. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of  self-violence or violence  towards an ascertainable victim; or if I am involved in criminal activity

I also understand that the dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my written consent.

2. I understand that there are risks and consequences from online counseling, including, but not limited to, the possibility, despite reasonable efforts on the part of my therapist, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.

In addition, I understand that online counseling based services and care may not be as complete as face-to-face services. I also understand that if my therapist believes I would be better served by another form of psychotherapeutic services (e.g. face-to-face services) I will be referred to a psychotherapist who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my therapist, my condition may not be improve, and in some cases may even get worse.

3. I understand that I may benefit from online counseling, but that results cannot be guaranteed or assured.

4. I understand that I have a right to access my medical information and copies of medical records, however none of them can be used for any medico-legal cases.

5. It is important to realize that online therapy is intended to provide quality information, practical answers to psychological issues, and online therapy for present problems. This service is not intended to provide in-depth psychotherapy as this particular venue is not entirely suited for such purposes.

I agree to give a 24 hour cancellation notice to my therapist in order not to be billed for the session.
I have read and understand the information provided above. I have discussed it with my therapist, and all of my questions have been answered to my satisfaction.

If an emergency situation or a life threatening crisis arises that requires immediate attention, you may call the emergency numbers of your state or go to a hospital emergency room.