Introduction
Telehealth involves the use of electronic communications to enable mental healthcare providers at different locations to share individual patient mental health information for the purpose of improving patient care. Providers may include mental healthcare practitioners,
specialists, and/or sub-specialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:
· Patient mental and medical records
· Live two-way audio and video
· Output data from psychological and neuro-psych testing results and sound and video files Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:
· Improved access to mental healthcare by enabling a patient to remain in his/her mental healthcare practitioner’s office (or at a remote site) while the professional obtains test results and consults from mental healthcare practitioners at distant/other sites.
· More efficient mental health evaluation and management.
· Obtaining expertise of a distant specialist.

Possible Risks:
As with any physical or psychological healthcare procedure, 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 mental healthcare practitioner
and consultant(s);
· Delays in mental health evaluation and treatment could occur due to deficiencies or failures of the equipment;
· In very rare instances, security protocols could fail, causing a breach of privacy of personal mental health information;
· In rare cases, a lack of access to complete patient records may result in adverse drug interactions or allergic reactions or other judgment errors;

By signing this form, I understand the following:
1. I understand that the laws that protect privacy and the confidentiality of mental health information also apply to telehealth, and that no information obtained in the use of telehealth which identifies me will be disclosed to researchers or other entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand that I have the right to inspect all information obtained and recorded in the course of a telehealth interaction, and may receive copies of this information for a reasonable fee.
4. I understand that a variety of alternative methods of mental healthcare may be available to me, and that I may choose one or more of these at any time. My mental healthcare professional
has explained the alternatives to my satisfaction.
5. I understand that telehealth may involve electronic communication of my personal mental health information to other healthcare practitioners who may be located in other areas, including out of state.
6. I understand that it is my duty to inform my mental healthcare practitioner of electronic interactions regarding my care that I may have with other healthcare providers.
7. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.

I have read and understand the information provided above regarding telehealth, have discussed it with my mental healthcare practitioner or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the
use of telehealth in my mental health care.