I have chosen to receive services from the Neighborhood Counseling Center by means of telehealth sessions. The potential benefits and risks of receiving services in this manner has been sufficiently explained.
• It is understood that services can still be provided in person at the clinic offices at my request and that there is always an option to withdraw this consent.
• It has been explained to me that there may be circumstances in which receiving services by telehealth may not be in my best interests. For example if there are any concerns for my safety and/or my condition that have been determined by clinical assessment to be best served by in-person services then it may be necessary to discontinue telehealth services. Should this become necessary it is understood that this may be a temporary measure however the length of time this will remain in effect will be determined by my clinical needs and condition. It has been explained to me that my preference will be given serious consideration.
• It has been explained to me that I must be present in the New York City area in order to receive services via telehealth. There can be exceptions to this as long as any travel outside of New York City does not involve a permanent re-location and are limited to brief periods that do not exceed 30 days. It is understood that during any period of travel outside of the local area that the telehealth session will be limited to the continental United States.
• It has been explained to me that telehealth services are considered more effective when conducted by means of video. The above stipulations have been carefully reviewed as my signature below provides authorization to receive telehealth services at the neighborhood Counseling center. Telehealth policies were reviewed and verbal consent was provided to intake coordinator during initial intake phone screening.