I
hereby consent to engage in online and/or telephone therapy services for myself/my child through West County Psychological Associates (WCPA).
I understand that online counseling/teletherapy may include consultation, therapy, assessment, diagnosis, transfer of medical data, telephone conversations, and education using interactive audio, video, or data communications. I understand that online counseling/teletherapy also involves the communication of my medical/mental health information, or that of my child, both verbally and visually.
I understand that I have the following rights with respect to online counseling/teletherapy:
By signing below, I acknowledge that I have both read and understood the information in this document and in West County Psychological Associates Informed Consent for Therapy Services, and agree to the terms of both documents. This consent ends when I notify my therapist that I am terminating telephone and/or online-based therapy or one year following my last therapy session.
In the case of a minor client, the signature of a parent is required.
NOTE: If parents are divorced or legally separated, the signatures of both parents are required unless otherwise stated in the legal parenting plan.