I,________________________, agree to participate as a patient of CM Therapy, LLC (“CM Therapy”) within its telehealth program and system. I will be receiving mental health services through interactive videoconferencing or other forms of online therapy. I understand the use of videoconferencing or online therapy is an alternative method of mental health care delivery and that my therapist will not be physically in the same room with me.
I understand that although CM Therapy makes every effort to protect my privacy by using a secure server, it, or any of its members or agents, cannot guarantee the security of any information I transmit to CM Therapy over the internet. By using telehealth services, I recognize that transmissions over the internet are at my own risk and that third parties may unlawfully intercept or access the transmissions. I also understand that despite reasonable efforts on the part of my therapist, there are risks and consequences in using telehealth services. The risks include, but are not limited to, the possibility that the transmission of sessions could be disrupted or distorted by technical failures. In case of technical failures, my therapist will make every effort to re-connect with me; however, I agree to utilize efforts to reconnect with CM Therapy to ensure the session will be completed.
I also understand that telehealth services may not be as complete as services provided via face-to-face, although, several benefits of telehealth services have been identified including increased access to specialized services in remote areas, lower healthcare costs, reduced travel, minimizing time off work, and decreased waiting time for services. I have also been notified that if my therapist believes I would be better served by another form of counseling services (e.g., face-to-face services), CM Therapy shall have the sole right to terminate me from its telehealth system and I will be referred to a therapist who can provide such alternate services. Finally, I understand that there are potential risks and benefits associated with any form of mental health service and that, despite my efforts and the efforts of my therapist, my condition may not improve and or resolve my specific issues. I understand that my participation in this is voluntary and I may decide to terminate my treatment at any time. My privacy and confidentiality will be protected.
I understand that there will be no recordings of my therapy sessions. I also agree to not record my own therapy sessions without my therapist’s knowledge or permission.
I understand that the telehealth services will be provided to me free of charge.
I hereby give my consent to receive mental health services through the CM Therapy telehealth program and system. I also understand that the services I receive will become part of record at any applicable referring agency and or will also be kept on file at CM Therapy. By signing this consent, I acknowledge that I have both read and understood all the terms and information contained herein.

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