Telehealth Policy & Consent
Somatic therapy services may be delivered via telehealth format. This policy covers both a description of how telehealth sessions work, what information may be used and disclosed, and your consent to utilize this method of service delivery.
1. Telehealth Informed Consent
- I understand that my health care provider and I are agreeing to engage in somatic therapy and health coaching services by way of a telehealth online video platform such as Zoom.
- My provider explained to me how the video conferencing technology that will be used to engage in such services will not be identical to an in-person direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
- I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
- I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
- I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. 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.
2. Policies for Client Telehealth Sessions
- Hold the session in an appropriate, safe, and private room.
- Do not have anyone else in the room or within earshot, unless you first discuss it with your therapist.
- Do not record sessions without first obtaining your therapist’s approval.
- Do not conduct other activities while in session, such as driving.
- Be located within the state in which the clinician is licensed to practice (client should inform their therapist of their location).
- Do not bring any weapons of any kind to session.
- Dress appropriately.
- Avoid using mind-altering substances prior to, or during, session.
3. Consent to Use the Zoom Platform, Phone, and Conference Meeting/Recording Service and Dropbox as a secure Cloud Storage Software ("Telehealth Service Platform"):
- Zoom is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use via both phone, internet, and offers options for both video and audio only sessions. There are no passwords required to log in.
- By signing this document, I acknowledge Zoom is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
- Though my provider and I may be in direct, virtual contact through the Telehealth Service Platform, neither Zoom, Dropbox, nor The Body Intuitive provide any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
- The Telehealth Service Platforms facilitates videoconferencing and archiving of videoconferencing for the purpose of support client care delivery and treatment progress; the Telehealth Service Platforms are not responsible for the delivery of any healthcare, medical advice or care.
- You agree and consent to the knowledge that your provider does not have access to any or all of the technical information in the operations of the Telehealth Service Platforms – or that such information is current, accurate or up-to-date.
- You agree and certify that you will not rely on your TBI health care provider to have any of this information in the Telehealth Service Platforms.
- To maintain confidentiality, you agree that youu will not share my telehealth appointment link with anyone unauthorized to attend the appointment.
Client recitals and certifications:
- 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.
BY SIGNING THE WAIVER I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
{Check box and signature provided on client intake forms when signing up for services}
{Check box and signature provided on client intake forms when signing up for services}
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on 04/01/2025
