Please read and fill out the following form to grant yourself (adult) or your child's consent to receive virtual therapy sessions with Clear Mind Therapy Solutions and its children's therapy division, Joyful Minds.
I understand the following regarding virtual therapy sessions:
1. I understand I have the right to withdraw my consent at any time.
2. I understand that there are risks, benefits, and consequences associated with virtual therapy, including but not limited to; network or signal interruption, unauthorized access and disclosure of client confidentialities, and limited manpower capabilities to respond to a client's emergency.
3. I understand that there will be no recording of the virtual therapy session by either party, and all information disclosed within sessions may not be released to anyone without the client's written authorization, except if required by law.
4. I understand that virtual-based therapy services may not be as thorough as in-person therapy services. If the therapist/life coach believes I would be better suited to attending an in-person therapy service, a referral list will be given of potential professionals who provide in-person therapy services.
5. I understand that virtual therapy does not provide emergency services for severe cases of depression or anxiety. During the first virtual therapy session, the therapist/life coach and I will review an emergency response plan. If I experience an emergency, I understand that I will call 911 or proceed to the nearest emergency room for help.
6. I understand that if I am experiencing suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) for free 24-hour support.
7. I understand that we could encounter technical difficulties resulting in the interruption of service. If this occurs, please end and reconnect. If the connection cannot be regenerated, please call me at (845)-418-3329 to discuss a rescheduling that best fits your calendar.
