Teletherapy Consent

Your name (required)Date of birth (required)Email address (required)Phone number (required)

Where you'll be

Address you'll usually be at during sessions (required)Country and region (required)Will you sometimes be somewhere else? (required)Where will you take the session? (required)

I understand I'm responsible for finding a private space, and that others may overhear if I don't (required)

I'll use headphones where I can

Technology

What will you use? (required)How reliable is your internet? (required)

If the connection fails and we cannot restore it within five minutes, I will call you on the number above and we will continue by telephone. If I cannot reach you, I will email you to rearrange.

I agree to the plan above if the technology fails (required)

May sessions be recorded for your clinical record? (required)

I will not record sessions without agreeing it first (required)

Emergencies

Emergency contact - name, relationship and number (required)Your doctor's practice and location (required)

Online therapy is not an emergency service. If you are in crisis, contact your doctor, a crisis line or emergency services - do not wait for a session.

I understand this is not an emergency service and know who to contact in a crisis (required)

I consent to receiving therapy online (required)