Online Counseling Consent Form
Terms & Conditions for Online Counseling Services:
Clients interested in receiving online counseling services must be at least 18 years-old.
Client eligibility and acceptance will be based on whether online counseling services is appropriate for a potential client. If it is determined that online counseling would not be in the best interest of a potential client, alternative therapeutic interventions will be recommended.
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). You may be asked to present a copy of your state license in order to verify your name and birth date.
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, clients in crisis or diagnosed with major mental health issues.
Online counseling does not provide crisis counseling and is not intended for clients who:
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 Mental Health 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 video conference. 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 and New Jersey.
Disadvantages include varying time zones, cultural differences, language barriers, and strength of internet connection which may impact the delivery of services. Clients must provide off-line contact information in case of a technology breakdown.
Online counseling is meant for clients who are not in major crisis nor been diagnosed with major mental health issues.
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.
Agreement:
This Agreement shall be interpreted only in accordance with the laws of the State of New York and New Jersey (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 or New Jersey.
Privacy Policy:
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.
Professional Records:
I am required to keep records of the psychological services that I provide you. Although psychotherapy often includes discussions of sensitive and private information, I keep very brief records indicating whether or not you attended your session, noting themes and topics we discussed, and interventions used in session. You have the right to request that a copy of your file be made available to any other health care provider at your written request when you sign a written authorization form that meets certain legal requirements imposed by HIPAA.
Urgent Contact Policy:
I am sometimes not immediately available by phone. While I am frequently available during normal business hours, I do not answer my phone when I am with a client. If you need to reach me between sessions, you may leave me a message on my voicemail. Your voicemail will be returned as soon as possible and by the end of the next business day, including voicemails and e-mails received on the weekend or after 5 p.m. on a weekday.
If your call or message is urgent, please be sure to let me know and leave a phone number where you can be reached. DO NOT EMAIL OR TEXT IF URGENT. If it is an emergency and I can't be immediately reached, call 911 or go to your nearest emergency room.
I will make every attempt to get in touch with you as soon as possible. I will always inform you in advance of any planned absences, and provide you with a name and phone number of a therapist covering the practice if my absence exceeds two weeks.
Social Media Policy:
I do not accept friend or contact requests from current or former patients on any social networking site (Facebook, LinkedIn, Instagram, etc). I believe that adding you as a Friend or Contact on these sites compromises confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship.
Pre-Payment & Cancellation Policy:
Online counseling appointments require pre-payment. If you fail to pre-pay for your session, your appointment will be cancelled unless other arrangements have been made ahead of time.
Psychotherapy is only effective when appointments are kept consistently. The time scheduled for your appointment is reserved for you and you alone. If you need to cancel or reschedule a session, I require at least 24 hours notice.
If you miss a session without canceling, or cancel with less than 24 business hours’ notice, you will be charged your full session fee. In addition, you are responsible for coming to your session on time and at the time scheduled. If you are late, your appointment will need to end on time.
Legal Fees:
Legal fees for any court-related activities (e.g., responding to a subpoena for records or court appearances) will be charged at $200 per hour of service provided, to be pro-rated by the half hour.
Please indicate agreement to the following by providing your initials below.
I am in agreement with the full mental health disclosure policy ____ (initial here)
I am in agreement with the pre-payment and cancellation policy ____ (initial here)
I am in agreement with the professional records policy ____ (initial here)
I am in agreement with the the legal fees policy: ____ (initial here)
Your full signature below indicates that you have read this Agreement and understand and agree to its terms. It also serves as an acknowledgment that you have received the HIPAA Notice Form described above. By signing this document, I hereby give my consent to participate in online psychotherapy with Alexis Auleta, LCSW.
Client Name: ____________________________________
Client Signature: ____________________________________
Date of Consent: ____________________________________
Emergency Contact Name : ___________________________
Emergency Contact Phone : __________________________
Clients interested in receiving online counseling services must be at least 18 years-old.
Client eligibility and acceptance will be based on whether online counseling services is appropriate for a potential client. If it is determined that online counseling would not be in the best interest of a potential client, alternative therapeutic interventions will be recommended.
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). You may be asked to present a copy of your state license in order to verify your name and birth date.
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, clients in crisis or diagnosed with major mental health issues.
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 Mental Health 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 video conference. 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 and New Jersey.
Disadvantages include varying time zones, cultural differences, language barriers, and strength of internet connection which may impact the delivery of services. Clients must provide off-line contact information in case of a technology breakdown.
Online counseling is meant for clients who are not in major crisis nor been diagnosed with major mental health issues.
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.
Agreement:
This Agreement shall be interpreted only in accordance with the laws of the State of New York and New Jersey (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 or New Jersey.
Privacy Policy:
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.
Professional Records:
I am required to keep records of the psychological services that I provide you. Although psychotherapy often includes discussions of sensitive and private information, I keep very brief records indicating whether or not you attended your session, noting themes and topics we discussed, and interventions used in session. You have the right to request that a copy of your file be made available to any other health care provider at your written request when you sign a written authorization form that meets certain legal requirements imposed by HIPAA.
Urgent Contact Policy:
I am sometimes not immediately available by phone. While I am frequently available during normal business hours, I do not answer my phone when I am with a client. If you need to reach me between sessions, you may leave me a message on my voicemail. Your voicemail will be returned as soon as possible and by the end of the next business day, including voicemails and e-mails received on the weekend or after 5 p.m. on a weekday.
If your call or message is urgent, please be sure to let me know and leave a phone number where you can be reached. DO NOT EMAIL OR TEXT IF URGENT. If it is an emergency and I can't be immediately reached, call 911 or go to your nearest emergency room.
I will make every attempt to get in touch with you as soon as possible. I will always inform you in advance of any planned absences, and provide you with a name and phone number of a therapist covering the practice if my absence exceeds two weeks.
Social Media Policy:
I do not accept friend or contact requests from current or former patients on any social networking site (Facebook, LinkedIn, Instagram, etc). I believe that adding you as a Friend or Contact on these sites compromises confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship.
Pre-Payment & Cancellation Policy:
Online counseling appointments require pre-payment. If you fail to pre-pay for your session, your appointment will be cancelled unless other arrangements have been made ahead of time.
Psychotherapy is only effective when appointments are kept consistently. The time scheduled for your appointment is reserved for you and you alone. If you need to cancel or reschedule a session, I require at least 24 hours notice.
If you miss a session without canceling, or cancel with less than 24 business hours’ notice, you will be charged your full session fee. In addition, you are responsible for coming to your session on time and at the time scheduled. If you are late, your appointment will need to end on time.
Legal Fees:
Legal fees for any court-related activities (e.g., responding to a subpoena for records or court appearances) will be charged at $200 per hour of service provided, to be pro-rated by the half hour.
Please indicate agreement to the following by providing your initials below.
I am in agreement with the full mental health disclosure policy ____ (initial here)
I am in agreement with the pre-payment and cancellation policy ____ (initial here)
I am in agreement with the professional records policy ____ (initial here)
I am in agreement with the the legal fees policy: ____ (initial here)
Your full signature below indicates that you have read this Agreement and understand and agree to its terms. It also serves as an acknowledgment that you have received the HIPAA Notice Form described above. By signing this document, I hereby give my consent to participate in online psychotherapy with Alexis Auleta, LCSW.
Client Name: ____________________________________
Client Signature: ____________________________________
Date of Consent: ____________________________________
Emergency Contact Name : ___________________________
Emergency Contact Phone : __________________________
