Virtual Therapy Consent Form

Please read the following document prior to meeting with a therapist as it will be reviewed during your first appointment.

What is virtual therapy?

Virtual therapy is the practice of therapy between a mental health professional and a patient using virtual means such as videoconferencing, phone calls, and any kind of electronic communication. In general, virtual therapy has the same benefits as face-to-face therapy. However, it also has some risks, which will be described below.

As a patient, I understand the following rights, responsibilities, and risks with respect to virtual therapy:

• I have the right to withhold or withdraw my consent at any time.

• My geographical location must always be disclosed so that the therapist may confirm they are not engaging in illegal practice due to license restrictions.
• I understand that the therapist is subject to the same standards of confidentiality as with face-to-face therapy. Therefore, any and all information disclosed during a session will be held strictly confidential and will only be accessed if necessary by members of Dialogue’s multidisciplinary team for the purpose of providing you care. This information will not be shared outside of Dialogue without my consent except in situations where the law requires it (for example, if I am a danger to myself or others, if a child’s security is compromised, or if a court waives my therapist’s duty of confidentiality).
• I am aware that my therapist will record my personal information in my record, according to his/her college’s standards and employer policy. This information will be kept strictly confidential as described in Dialogue’s privacy policy.
• I recognize that despite best efforts to ensure high encryption and secure technology on the part of my service provider, there is no guarantee that my personal information may not be accessed by unauthorized persons.
• I understand that in order to safeguard my personal information and in respect to the therapist's rights to privacy, I should attend my sessions from a private location where no one else will be able to overhear. Additionally, I will ensure that I am connected to a secure and stable internet connection. 
• As described in Dialogue’s Terms of use, Dialogue does not provide emergency services. If there is an emergency situation, I am aware that I should call 911 or proceed to the nearest hospital emergency room for help. 
• I understand that my therapist may contact emergency services on my behalf if he/she has reasonable reasons to believe I am in danger of hurting myself or others.
• I am aware that my therapist will constantly assess the appropriateness of virtual therapy and may suggest in-person sessions if necessary. 

Other considerations:

Short-term therapy: It is usually defined as a number of limited sessions that relate to a clearly defined goal. The number of sessions and goal(s) will be decided together with my therapist. It allows the therapist and the patient to build a therapeutic relationship that will help to increase awareness of mental health issues and implement lasting change. 

Technological issues: I should discuss with my therapist a plan to establish communication should our session be interrupted due to technical difficulties (it should be noted that the therapist cannot communicate with me with their personal phone number or with their personal email address).

Cancellation policy for appointments without fee: I can cancel or reschedule any session up to 24 hours in advance. I may be charged an 80$ fee for any late request or missed appointment. I understand that Dialogue reserves the right to cancel my appointment if I am more than 5 minutes late, if my environment is not safe or private, or if communication is not secure.

Fee:  If a fee is applicable, it can be paid via the Dialogue application with a credit card or a prepaid card. If I am late for my appointment, it will end at the time initially planned, and I will have to pay the amount for a full session. In the case where my therapist is late, they will suggest another time so that I can benefit from a full session. Finally, I understand that prices are subject to change. I will be informed of any such changes prior to initiating a new session.

If I have any questions or concerns, I can discuss them with my therapist. 

I have read, understood, and agree with the information provided above. I will confirm my acknowledgment in the chat where I received this document.