I hereby consent to participate in telehealth services with Petal Psychiatry. I understand that telehealth is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.

I understand the following with respect to telehealth:

• I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.
• I understand that there are risks, benefits, and consequences associated with telemental health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
• There are potential risks associated with the use of telehealth.

These risks include, but may not be limited to:

• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate decision making by the providers.
• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment required for appointment.
• In very rare instances, security protocols could fail, causing a breach of privacy of personal health information.

Prohibited Action and Visit Expectations:

1. Not be in a moving car or operate any machinery/appliances/tools, etc.
2. Dress appropriately
3. Can be seen fully via the camera, if needed
4. Be in a secure and safe location
5. Be in a private setting and uninterrupted by surrounding environment/people/pets, etc.
6. Not be eating

• I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
• I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telehealth unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).
• I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telehealth services are not appropriate and a higher level of care is required.
• I understand that during a telehealth session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, please call the office to discuss since we may have to reschedule.
• I understand that my therapist/nurse practitioner/ physician assistant may need to contact my emergency contact and/or appropriate authorities in case of an emergency.