Informed Consent for Distance Counseling
(Online Video, Telephone)
This agreement is an addendum to the Counseling Agreement with Charles Hughes Counseling Services, PC.
I, ________________________________ (Client) agree to engage Charles Hughes, LCPC (Counselor) to provide counseling or psychotherapy services via online video counseling or by telephone. I understand that Distance Counseling may not be covered by insurance in Illinois and will not be submitted by the Counselor to insurance. I agree to pay for such services at the time of service at the rate stated in the Schedule of Fees.
Limitations of Distance Counseling
I understand that Distance Counseling or therapy differs from face-to-face sessions. The differences include a lack of “body language” or other communication cues. Facial expression and tone of voice may be harder to read.
Technical difficulties can occur such as internet slowdown or connection failure. In such case, the Counselor would call me by phone so that we can complete our session or confirm a new appointment time.
If I am prescribed medication by a psychiatrist or doctor, I understand that Distance Counseling is not a substitute for such medication. I will consult with my psychiatrist or doctor before discontinuing medication.
I understand that Distance Counseling or therapy is not appropriate if I am experiencing a mental health crisis or having suicidal or homicidal thoughts. If I experience such a life-threatening crisis, I agree to contact a crisis hotline, call 911, or go to a hospital emergency room. I understand that if the Counselor believes I am experiencing a mental health emergency, he will call my emergency contact, and, if appropriate, the police or 911.
Mode of Conducting Distance Counseling
Distance Counseling will be conducted through a secure website that provides online video conferencing for counseling and therapy. The Client will be responsible for registering for a account which will be free to the client. A test session will be held between Client and Counselor to be sure the service is working at no charge to the client.
Prior to the commencement of Distance Counseling, the Client will be asked to read and sign the same forms as would be used for face-to-face counseling. These forms must be signed and returned to the counselor prior to the first session.
The Client agrees to pay for each session in advance by credit card unless insurance is being used. In that case, the client agrees to pay the insurance co-pay or co-insurance in advance of the distance counseling session.
The Process of Distance Counseling
I understand that I must have a private location for my distance counseling sessions. No other person may be present in the location during sessions. I understand that a session may be ended, at the Counselor’s discretion, if he does not think my location is private.
I understand that the Counselor is currently licensed to practice only in the State of Illinois and that I must be physically present in Illinois during each session. Exceptions may be possible with sufficient advance notice if I am travelling and wish to conduct a session from out of Illinois.
I understand that no recording of the sessions by any form whatsoever is allowed and that such recording will be considered grounds for terminating counseling.
I understand that phone counseling is used only for short support sessions (usually less than 30 minutes), when face-to-face and video sessions are not available or practical.
I understand that the Counselor does not conduct counseling or therapy by email or text message.