Online Counseling Consent Form
Terms & Condition for Online Counseling Services:
Clients interested in receiving online counseling services must be at least 18 years-old.
Clients interested in online counseling services must consult with Alexis Auleta, LCSW to discuss eligibility as well as the terms and conditions that apply to said services. If it is determined that online counseling is appropriate, clients must submit written verification to the terms and conditions (see below) before services are rendered.
Eligibility for Online Counseling Services:
Online counseling services are not meant to take the place of direct, face-to-face psychotherapy services.
Online counseling services are most suitable for clients over the age of 18 years-old who have either previously engaged in formal counseling services and/or are seeking short-term support for issues that are unrelated to major crisis, severe mental health issues, suicidal, homicidal or violent behavior (past and present).
Online counseling services are intended for clients who have limited access, availability or financial means to receive direct, face-to-face professional counseling services.
Although online counseling services may be helpful, direct, face-to-face services are highly recommended and encouraged, especially for clients either looking for long-term treatment or clients in major crisis.
Online counseling does not provide crisis counseling and is not intended for clients who:
- Have a history of major psychiatric episodes, hospitalizations or drug/alcohol dependence.
- Have been diagnosed as any of the following - Borderline Personality Disorder, Major Depressive Disorder, Bipolar Disorder Type 1, Mentally Ill/Chemically Addicted (MICA), and/or Schizophrenia.
- Have a history of suicidal, homicidal or violent behavior or present as suicidal, homicidal or violent.
If you are considering suicide, or believe yourself to be a potential safety threat to others, you must immediately call 911, (800) LIFE-NET and/or notify the police and/or seek emergency care at your local hospital.
Full Client Disclosure & Right To Refuse Online Counseling Services:
If you have any history of major psychiatric episodes, hospitalizations or drug/alcohol dependence or have been diagnosed as any of the following - Borderline Personality Disorder, Major Depressive Disorder, Bipolar Disorder Type 1, Mentally Ill/Chemically Addicted (MICA), and/or Schizophrenia - you must disclose this information to Alexis Auleta, LCSW prior to being considered for online counseling services.
Failure to do so or knowingly misleading or withholding the above said information excludes Alexis Auleta, LCSW from any legal obligation or liability related to said client’s diagnosis, prognosis, outcome and actions.
If it is deemed at any point in the treatment that your needs are greater than Alexis Auleta’s area of expertise or scope of practice and a client is unsuitable for online counseling services, Alexis Auleta, LCSW reserves the right to refuse and/or end treatment and appropriate referral sources will be provided.
About Distance Counseling:
Also known as Telepractice, Cyberpsychology, Text-Based Therapy, Telehealth, Behavioral Telehealth, and Online Therapy. Distance counseling is providing a psychotherapy service that is not “in person” and is facilitated through the use of technology. Such technology may include, but is not limited to, telephone, telefax, email, internet, or videoconference. Distance Counseling is subject to all practice and ethical considerations discussed in this document and in the law, rules and regulations governing licensed practice in New York State.
Disadvantages include varying time zones, cultural differences, language barriers, and strength of internet connection which may impact the delivery of services. Clients may provide off-line contact information in case of a technology breakdown.
Scope of Practice:
This term indicates the specific area to which a practitioner may practice. Alexis Auleta, LCSW, follows local and regional laws and codes of ethics as applicable to a client’s geographic location.
According to national licensure requirements, Alexis Auleta, LCSW, is permitted to provide psychotherapy services in all states excluding: Arkansas, Florida, and Nebraska which issue geographical boundaries for distance counseling and require practitioners to be licensed by that state.
If an individual from Arkansas, Florida, or Nebraska chooses to engage in counseling with Alexis Auleta, LCSW, you understand and acknowledge that you will not be receiving state-licensed services.
Alexis Auleta’s services are not open to those living in a country that is prohibited by law, regulation, treaty, or administrative act from entering into trade relations with the United States.
Nature of Counseling:
There may be both benefits and risks while participating in counseling, distance or otherwise. Counseling may improve your ability to relate with others, provide a clearer understanding of yourself, your values, and your goals. Since counseling may also involve discussing unpleasant aspects of your life, you may also experience uncomfortable feelings. Counseling often leads to better relationships, solutions to specific problems, and significant improvement in feelings of distress.
However, please understand there are no guarantees of what you will experience, and that you enter this Agreement and use Alexis Auleta, LCSW’s services at your own risk. You agree that you understand the possible advantages and disadvantages of online therapy and shall not hold Alexis Auleta, LCSW legally liable for any information or insight distributed here.
This Agreement shall be interpreted only in accordance with the laws of the State of New York (excluding any rules governing choice of laws), and any legal proceeding associated with this Agreement will occur exclusively in the courts located in New York, New York.
According to mental health licensing statutes, the law protects the privacy of all communications between a client and practitioner. Alexis Auleta, LCSW’s practice is in compliance with the requirements of HIPPA. Confidentiality is taken seriously and discussing or releasing your information to any individual, agency, or corporation except if such release is requested by a signed authorization form; or if a client indicates intent to do harm to her/himself or others.
Limits of Confidentiality:
There are some situations in which practitioners are legally and ethically obligated to take actions they believe may be necessary to protect a client or others from harm. If such a situation arises, Alexis Auleta, LCSW will make every effort to fully discuss the issue with the client before taking any action and will limit disclosure to only what is necessary.
If a practitioner has reason to believe that a child or vulnerable adult is being neglected or abused, the law requires that the situation be reported to the appropriate state agency.
If a client presents a clear and substantial danger of harm to himself/herself or others, Alexis Auleta, LCSW is ethically obligated to take protective actions.
These actions may include contacting family members, assisting with hospitalization, notifying any potential victim(s), and notifying the police.
*I have read, understood and agreed to the policies stated above and hereby give my consent to participate in online psychotherapy with Alexis Auleta LCSW.
Client Name: ____________________________________
Client Signature: ____________________________________
Date of Consent: ____________________________________
Emergency Contact: (Name/Phone) : _________________________________
Alexis Auleta, LCSW
15 Village Plaza
S. Orange, NJ 07079