The following information is to be completed by the person being served, also designed as “client”. The purpose of this document is to inform you, the client, about relevant aspects of online therapy services. Please read this entire document, sign, and return it via email (Please send a readable image or pdf file to email@example.com).
Online Therapy/ Telepsychotherapy: Psychotherapy will be conducted using interactive audio and/ or video. If this type of services seems not to be appropriate for your needs, face-to-face psychotherapy services will be suggested. Email contacts are allowed regarding the schedule of sessions or changes in contact information, not as a form of online therapy. Before each session you will be provided by email a link for a safe online therapy environment to use (complying with the Health Insurance Portability and Accountability Act), provided you have a private place to be with your computer with camera and/ or audio.
Confidentiality: The information disclosed during the course of psychotherapy is confidential, however there are legal exceptions both mandatory, and permissible, related to risk or harm to self or others, or if court ordered. The therapist will take all precautions to ensure online therapy is confidential, but client is informed that transmission could possibly be interrupted or accessed by unauthorized persons. Although the internet provides the appearance of anonymity and privacy in counseling, there are some risks. To minimize them, the therapist will use the “Zoom” app to best comply with HIPAA in order to protect you, and sessions will not be recorded. The client is responsible for securing his or her own computer hardware, internet access points, and password security. The client recognizes that any contact made via email might not be as safe, and therefore acknowledge this is a reason why email will not be considered a privileged form of interaction nor a service for online therapy in this case.
Appointments and Charges for Services: Payment will be made via PayPal at least 24h before the session. If the client do not show up for your session after payment, there are no refunds, as the therapist will be available to you for the whole duration of the session (1h). Cancellations or reschedules can be made with a minimum of 24h notice, at no cost for you. If by any reason the therapist might need to reschedule the session, the same rules will apply, meaning that with a 24h notice the client will be given an alternative schedule of his or her choice, and if the therapist notice does not occur at least 24h before the session, the rescheduled session will not be paid by the client.
Limitations: Any contact made via email will be answered by the therapist, as soon as possible, but it might take more than 24h to do so. From time to time, sessions might be disturbed or distorted by technical failures and this is accounted for. In the event of a personal crisis, such as thoughts of harming yourself or others, you or the therapist should contact:
Emergency contact (name/ contact): ______________
Emergency number in area of residence: ___________
Procedures should we encounter technical difficulties or disruptions in service: It is understood that when communicating by internet or other electronic means, disruptions in service or other technical difficulties might likely occur from time to time. If it is the case, the therapist will provide via email a new link for the session. If the problem is not rapidly resolved due to the therapist responsibility, the therapist will reschedule a new session for the duration of the time of the session lost, at no cost for the client. It is also agreed between the two parts, that both will be responsible to provide an adequate internet connection, to prevent such incidents for happening.
By signing this form:
- I state that I am an adult who resides in ____________ (full address).
- I agree to participate in online psychotherapy with a certified Psychotherapist in Portugal.
I have read, understood and comply with the agreed upon policies.
Signature of Client _________________Date ____/____/____
NIF/TIN/TFN ___________ (for receipt purposes, sent by email to the client)
| | By checking the box I agree that the signature I have entered above will be the electronic representation of my signature and initials for all purposes when I use them on documents, including legally binding contracts – just the same as a pen-and-paper signature.
Click here to download the pdf version.
NOTE: Internal Family Systems related interventions (IFS and IFIO, for individuals and couples) have a specific informed consent. I appreciate you kindly be in touch in case that is your interest (firstname.lastname@example.org).