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Inward Journey Counseling

Peoria Counseling Service

309-472-0798

Please download and complete the attached Tele-Mental Health Consent Form and email to our office at wisnumeier@inwardjourneycounseling or bring to your first appointment.

Tele-Mental Health Form

OR COMPLETE THE ONLINE FORM BELOW

Tele-Mental Health Consent Form

Tele-mental Health Informed Consent

Please take a moment to fill out the form before your first appointment.

Name

I hereby consnt to articipate in tele-mental health with Wisnu Meier of Inward Journey Counselng as part o my psychotherapy. I understand tele-mental health is the pactice of delivering clinical halth care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.

Your Signature

PLEASE READ EACH STATEMENT BELOW AND ACKNOWLEDGE SAME BY CHECKING THE CORRESPONDING BOX.

I understand I have the right to withdraw consent at any time without affecting my right to future care. or program benefits to which I would otherwise be entitled

I understand there are risks and consequences associated with tele-mental health, includig but not limte to, disrupton of transmision by technology failures, interrupton and/or breaches of confidentiality by unauthorized pesons, and/or limited ability to respon to emergecies.

I understand there will be no recordng of any ofthe onlin sessins by either party. All infrmaton disclosed within sessions and written recods pertaining to those sessions are confidential and may not be disclosed to anyone without written authorizaton, except where the disclosue is permited and/or required b law.

I understand the privacy laws that protect th confidentiality of my protected health infomatio (PHI) also apply to tele-mental health unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult ause; danger to self or others; I raise mental/emotional heatlth as an issue in a egal proceeding).

I understand if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined tele-mnenta health services are not appropriate and a higher level of care is required.

I understand if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined tele-mnenta health services are not appropriate and a higher level of care is required.

I understand I am responsibl for: a) providing the necessarycompute, telecommunications equipment and internet access or my teletheray sessions, b) ensuring securiy on my computer, and c) arranging a location with sufficient lighting and privacy that is fee from distractions or intrusions for my teletherapy session.

I understand during a tele-mental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, please call Wisnu Meier at 309-472-0798 to dicuss since we may have to re-schedule.

I understand my therapist may need to contact my emergecy contact and/or appropriate authorities in case of an emergency.

EMERGENCY PROTOCOLS

I understand my therapist needst know my location in case of an emergency. I agree to inform my therapist of the adress where I am at the beginning of each session. I also understand my therapist may need to contact someone on my behalf in a life-threating emergency only. This person will only be contacted to come to my location ort take me to the hospital in the event of an emergecy.

In case of an emergency, my location is:

My emergency contact person's name is:

My emergency contact person's contact phone is:

My emergency contact person's email is:

My emergency contact person's address is:

I have read the information povided above and discussed it with my therapist. I understand th information contained in this form and all of my questions have been answered to my satisfaction.

Signature of client/parent/legal guardian

Date form signed

Signature of therapist (will be done at your first appointment).

Date form signed by therapist ( will be done at your first appointment).

Thanks for submitting!

INWARD
JOURNEY
COUNSELING

© 2023 by Inward Journey Counseling

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Appointments:

T: 309-472-0798

F: 309-643-1227

wisnumeier@inwardjourneycounseling.com

7501 N University St Suite 225, Peoria, IL 61614

Home
Meet Your Therapist
Services & Rates
Groups & Workshops
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Scheduling & Payment
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