Informed Consent Form for Online Counseling Services

Lola Broomberg LPC

Lolabroomberg@gmail.com ·

541 686 8119

INFORMED CONSENT FOR ONLINE COUNSELING SERVICES

The purpose of this Informed Consent for Online Counseling Services is to share with you, the client, information about the process of online counseling services, the potential risks and benefits of these services, and alternatives to these services. This consent is an addendum to my Professional Disclosure Statement & Informed Consent that you are required to sign before beginning our work together.

A. Privacy & Confidentiality

Although the internet provides the appearance of anonymity and privacy in counseling, privacy is more of an issue online than in person. The client is responsible for understanding the potential risks of confidentiality being breached through unencrypted email, lack of password protection, or leaving information on a public access computer. Other potential risks of breaching confidentiality could include messages failing to be received if they are sent to the wrong address or if they are just not noticed by the counselor. Confidentiality could be breached in transit by hackers or internet service providers or at either end by others with access to the client’s account or computer. Clients accessing the internet from public locations such as a library, computer lab, or café should consider the visibility of their screen to people around them. Position yourself to avoid others seeing your screen. Using cell phones can be risky in that signals are scrambled but rarely encrypted. The client is responsible for securing their own computer hardware, internet access points, chat software, email and passwords that are encrypted, secure, and HIPAA compliant when possible. If encryption is not made available to client, client should be aware that they are risking unauthorized monitoring of transmissions and/or records of Internet counseling sessions.

I encourage you to only communicate through a computer wherein confidentiality can be ensured. I ask that you determine who has access to your computer and electronic information from your location. This would include family members, friends, acquaintances, and coworkers and whether or not confidentiality from your work or personal computer may be compromised. Be sure to fully exit all online counseling sessions and emails. Please do not record any portion of our sessions without my consent.

B. Lack of Non-Verbal Cues & Asynchronous Communication

Please be aware that misunderstandings are possible with online counseling, since non-verbal cues are relatively lacking. Misunderstandings may occur since bandwidth is always limited and images lack detail. Counselors are observers of human behavior and gather much information from body language, vocal inflection, eye contact and other non-verbal cues. Please clarify with me throughout our working relationship any information that you think I may not have understood well.

C. Benefits and Risks of Receiving Online Counseling Online

Counseling allows clients to be counseled from anywhere once one gains an internet signal and can operate the necessary hardware. However, there are risks related to providing online counseling services related to the technology used, the distance between counselor and client, and issues related to timeliness. Risks related to privacy and confidentiality were mentioned in Section A.

I have selected a video conferencing account that is encrypted with a HIPAA compliant secure platform to allow for the highest possible security and confidentiality of the content of your sessions. Your personal information is encrypted and stored on a secure server. The client is responsible for creating and using additional safeguards when the computer used to access services may be accessed by others such as creating passwords to use the computer, keeping their e-mail and passwords secret, and maintaining security of their wireless internet access points (where applicable.) Please discuss any such concerns with me during your first session so as to develop ways to limit risks. If there is ever a disruption or disconnection of services on the internet, please contact me at 541 686 8119.

D. Alternatives to Online Counseling, Termination & Referrals

Online counseling may not be appropriate for many types of clients, including those who have numerous concerns over the risks of internet counseling, or those clients crises or having suicidal or homicidal thoughts. Alternative to receiving mental health services online can include receiving mental health services with me in person, use of both modalities, or working with another counselor. If at any point during psychotherapy I assess that I am not effective in helping you reach your therapeutic goals, I am obliged to discuss this with you up to and including termination of treatment. You have the right to terminate therapy at any time. Please feel free to request a referral any time you think a different counseling relationship would be more practical or beneficial for you.

E. Records

I will maintain records of online counseling services. These records can include reference notes, copies of transcripts of internet communications, and session summaries. These records are confidential and will be maintained as required by applicable legal and ethical standards according to the American Counseling Association and the Oregon Board of Licensed Professional Counselors and Therapists. The client will be asked in advance for permission before recording any audio or video session.

F. Appointments & Fees

All policies related to appointments and fees outlined in my Professional Disclosure Statement and Informed Consent will apply to online counseling, except that payments will be processed online and will be due prior to beginning our session. If we are scheduled for an online synchronous audio or video conference and we are unable to connect or are disconnected during a session due to a technological breakdown, please try to reconnect within ten minutes. If reconnection is not possible, contact me at 541 686 8119 to schedule a new session time. In this case, your payment would be credited towards the new session.

G. Consent for Online Counseling Services

I, the client, have read and agree to the terms listed above in the Informed Consent.

I understand that Lola Broomberg is a Licensed Professional Counselor who follows the laws and professional regulations of the state of Oregon. I understand that treatment will be considered to take place in the state of Oregon unless the client resides in another state. If a client resides in a state where distance counseling is not provided, Lola will seek written permission from the Board in that state before providing services. I understand that licensing rules are different for each state. I understand that online counseling therapy is not appropriate if I am experiencing a crisis or having suicidal or homicidal thoughts. In case of emergency situations, I will contact the resources listed in the Professional Disclosure Statement and Informed Consent. I understand that this consent is an addendum to the Professional Disclosure Statement & Informed Consent and that all policies outlined therein also apply to online counseling services. I understand my signature is an agreement for online counseling services conducted by Lola Broomberg.

Please sign and date, giving your consent to begin online counseling services: _____________________ Client Name and Signature ___________Date _____________________ Client Name and Signature ___________Date _____________________ Client Name and Signature ___________Date