Telehealth involves the use of electronic communication to enable Journey Counseling
Ministries (JCM) clinicians to connect with individuals using live interactive video and audio communications. It does not include therapeutic services via email or text. Telehealth includes the practice of psychological health care delivery, consultation, treatment, referral to resources, education, and the transfer clinical data.

I understand that I have the rights with respect to telehealth:

1. The laws that protect the confidentiality of my personal information that I have already signed also apply to telehealth. Copy of our “Office Policies” and “Therapeutic Informed Consent” can be provided upon request.

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 there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the counselor, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons. JCM may utilize secure, encrypted HIPAA compliant audio/video transmission software to deliver telehealth. However, The US Department of Health and Human Services has issued a statement allowing telehealth to be done with non-HIPPA compliant platforms and software during this COVID-19 nationwide public health emergency. You can read this statement here: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

4. Journey clinicians follow the State of Virginia regulations for telehealth as well as their respective board regulations and ethics.

5. By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 911 or seek help from a hospital or crisis-oriented health care facility in my immediate area.

Distance counseling should not be viewed as a substitute for face-to-face counseling or medication by a physician. It is an alternative form of counseling with certain limitations.

By signing this document you agree that you understand that distance counseling:

• may lack visual and/or audio cues, which may cause misunderstanding.
• may have disruptions in the service and quality of the technology used.
• may not be appropriate if you are having a crisis, acute psychosis, or suicidal or
homicidal thoughts.

With the use of technology, it is important to be aware that family, friends, co-workers, employers, and hackers may gain access to any technology, devices, or applications that you use.

JCM encourages you to only communicate through a computer or device that you know is safe and to follow the safety measures detailed on the “How-Tos and FAQs” document sent to you via email. You are responsible for reviewing the privacy settings and agreement forms of any applications or technology you use.

So that your therapist is able to get you help in the case of an emergency and for your safety, the following are important and necessary. In addition, by signing this agreement form you are acknowledging that you understand and agree to the following:

• You, the client, will inform your therapist of your location during your sessions and will inform your therapist if this location changes.
• You, the client, will identify on this form a person whom your therapist is allowed to contact in the case that your therapist believes you are at risk.
• Depending on your therapist’s assessment of your risk, you or your therapist may be required to verify that your emergency contact person is able and willing to go to your location in the event of an emergency, and, if your therapist deems necessary, to call 911 and/or to transport you to a hospital. In addition, your therapist may assess, and therefore require, that you create a safe environment at your location during the entire time that you are in treatment. This may mean disposing of all firearms and excess medication from your location.

The most reliable backup is a phone. Therefore, we recommend that you always have a phone available and that your therapist knows your phone number.

If you get disconnected from a video conferencing session, end and restart the session. If you are unable to reconnect within five minutes, your therapist will call you on the number you provide at the top of this form (unless you request otherwise).

If you are on a phone session and your phone disconnects, wait for your therapist to call you on the number you provide at the top of this form (unless you request otherwise).

Payment is due at the time services are rendered. No-Show Fees apply.

If you are paying by check or cash, please mail your payment to:

Journey, PO Box 14
Dayton, VA 22821

JCM clinicians are also able to take credit cards manually.

I have read and understand the information provided above regarding telehealth, and all of my questions have been answered to my satisfaction. I have read this document carefully and understand the risks and benefits related to the use of telehealth services and have had my questions regarding the procedure explained.

I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein. By submitting this form, I hereby state that I have read, understood, and agree to the terms of this document.