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Telehealth Informed Consent

Consent Form – Please read carefully

Download a PDF version of the Consent Form HERE.

Telehealth is online or virtual counseling and has been found to be effective in treating the same conditions as in-person counseling. There are some differences between in-person counseling and telehealth counseling which you should be aware of. Please read this document carefully before consenting to telehealth services. As a part of telehealth sessions, you and your provider will communicate via a HIPAA compliant video platform and will exchange protected health information. The information that is exchanged may be used for diagnosis, counseling, follow-up and/or education, and may include any of the following: 

  • Patient medical records
  • Live two-way audio and video
  • Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data, and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:

  • Improved access to substance use treatment by allowing a client to remain in his/her to access counseling services outside of their immediate geographic area.
  • Increasing access to services for clients who are working by removing the need for commuting time to and from appointments.
  • Improving continuity of care for clients who have to move for job/family/life changes and preventing the need for changing providers due to a move.
  • Obtaining expertise of a specialist.

Possible Risks:

There are potential risks associated with the use of telehealth, as there are with all services. These risks include, but may not be limited to:

  • Unexpected technological problems or failures can result in a disruption in treatment.
    Counselors may miss important non-verbal communication that is not visible or detectable during telehealth sessions.
  • Transmission of and completion of documents and forms requires technological skill and may take longer to complete if the systems are unfamiliar to the client.
  • In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
  • In rare cases, a lack of access to complete medical records may result in inappropriate or inaccurate recommendations for level of care, referrals, etc.

Preparation for Your Session:

When participating in telehealth sessions with your provider, you will be expected to prepare yourself and your environment for each session. Participation in telehealth sessions will require you to do the following:

  • Select and prepare a confidential space in which to participate in your session. The room you select should be quiet, with a closed and/or locking door to prevent unintended interruptions.
  • Make sure you have a strong internet connection, your microphone and speakers are functioning, and that your device is fully updated before starting each session.
  • Find arrangements for child care if needed so that you can participate in the session without having to care for children at the same time.
  • Make sure you are fully dressed.
  • Be sure to eat and drink before session, as consuming food and drink during session can create a significant distraction and prevent your provider from understanding you fully.
  • Close all programs on your computer or stop all notifications on your smartphone, and close all browser windows to prevent distractions during your session and optimize the functioning of your device.
  • Identify the exact address of the location from which you will be participating in your telehealth session. Your provider will need to document the exact location at the start of each session.
  • Pay any copays or session fees before the session time using the payment button on the Collective Recovery website, If payment has not been made, your session will be cancelled and you may be charged a cancellation fee of $25.
  • Connect to the telehealth portal at least 5 minutes before your scheduled session time using the url/link provided. Your provider will give you access to the telehealth consultation room when they are ready.
  • If for some reason you are having trouble with the technology or the connection, you must inform your provider via phone or email.
  • In the event of a technology failure, your provider will make two attempts to contact you via email and/or phone using the contact information you have previously provided. If your provider is unable to reach you after two attempts or by ten minutes past the session start time, your session will be cancelled and will be considered a no-show, resulting in a cancellation fee if applicable.
  • Be sure to allot enough time for the session as scheduled (30 min, 45 min, 60 min, etc). Leaving early from a session may result in a cancellation fee.
  • Be sure to complete all therapy “homework” and upload any required or requested documents before session. Your provider will be better prepared to discuss these documents with you if they have had time to review your documents before session.

Cancellation Policy:

Telehealth sessions are just as important as in-person counseling sessions. Please make sure to attend all your sessions as scheduled. If you need to reschedule your appointment, please notify your provider via email or phone no later than 24 hours before your scheduled appointment time. For example, if your appointment is scheduled for Tuesday at 3:00pm, you must notify your provider of the need to cancel/reschedule no later than 2:59pm on Monday. Rescheduling requests or cancellations that are submitted less than 24 hours in advance may result in a late cancellation fee $25.

Fees and Payment:

Telehealth is covered by many insurance policies, but it is your responsibility to make sure you have both active coverage and to verify if your particular policy covers telehealth services. Your provider and/or other clinic staff will make an attempt to verify benefits for you prior to your sessions, but it is your responsibility to notify your provider of any changes in your coverage or any lapses that may occur. If you do not have insurance coverage, or choose not to use your coverage to pay for your telehealth sessions, you will be responsible for making payment prior to each session. If you have not made your payment before your scheduled appointment time, your session will be cancelled and you will need to make payment before your next session can begin. Self-pay session fees are as follows:

  • Individual Counseling (60 minutes)- $100
  • Group Counseling (60 minutes minimum)- $45

Urine Drug Testing:

Routine Urine Drug Testing (UDT) is a routine part of substance use treatment and will be an expectation of your treatment participation through telehealth as well. Collective Recovery Center is contracted with Dominion Diagnostics for UDTs and you will be required to complete routine testing at Collective Recovery or at a testing site closest to your geographic location. If there is not a Dominion Diagnostics testing location near you, it will be your responsibility to identify a UDT site near you and establish a relationship for ongoing testing. This may result in additional fees which you will be responsible for. Please be sure to ask about the cost of testing at your chosen facility and find out whether or not they are able to bill your insurance. Collective Recovery Center is not responsible for the cost of testing at a non-contracted testing facility. Also, whether you are testing at a Dominion Diagnostics testing site or one of your choosing, you will be required to complete a consent form to release and receive information from your testing site which must remain active for the duration of your treatment episode. Refusal to consent to this release or revocation of this release may result in a termination of the treatment relationship with Collective Recovery Center. Testing is scheduled randomly and scheduling will be determined by your testing facility. Additional information on testing will be available in a separate document and will be specific to your testing facility.

In Case of Emergency:

In the event that your provider is concerned for your safety or the safety of others, it is important that we have an address for the location from which you will be engaging in telehealth sessions. Your provider is trained to assess for your safety and, if needed, may need to contact emergency services in your area if there is a concern for your safety or the safety of others. For more information about mandatory reporting and emergency response policies, please talk with your provider.

Termination of Treatment:

When you feel you are ready to end your treatment with Collective Recovery Center, please communicate with your provider about your plans to terminate treatment. Please note that telehealth providers are required to follow the same reporting requirements as in-person providers for mandated clients. Prior to ending treatment, it is recommended that you attend one or more termination sessions during which your provider will review your progress, update clinical recommendations, and refer you to additional services if applicable. Regular attendance is crucial to the effectiveness of your telehealth counseling. If you do not attend telehealth sessions for two weeks, you will receive a notice of pending discharge from treatment due to non-attendance. If you no-show two scheduled telehealth sessions and do not respond to your provider’s attempts to contact you, your treatment relationship with Collective Recovery Center will be terminated. It is your provider’s responsibility to complete ongoing assessments and this is not possible if you do not attend your appointments. If you need to stop your telehealth sessions for whatever reason, please notify your provider as soon as possible. By signing this Informed Consent document, you acknowledge that you understand and agree with the following:

  1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth, and that no information obtained in the use of telehealth, which identifies me, will be disclosed to researchers or other entities without my written consent.
  2. Understand the expectations of my participation in telehealth services through Collective Recovery Center and agree to meet all expectations listed in this document.
  3. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
  4. I understand the alternatives to telehealth consultation as they have been explained to me, and in choosing to participate in a telehealth consultation, I understand that some parts of the treatment may need to be completed by providers near me, or at a testing facility, at the direction of the consulting healthcare provider.
  5. I understand that telehealth may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
  6. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
  7. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my healthcare provider and consulting healthcare provider in order to operate the video equipment. The above mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my history that are personally sensitive to me; (2) ask additional personnel to leave the telehealth consultation room; and/or (3) terminate the consultation at any time.

Consent To The Use of Telehealth:

I have read and understand the information provided above regarding telehealth, have discussed it with my provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I have read this document carefully, and understand the risks and benefits of the telehealth consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telehealth visit under the terms described herein. By signing below, I hereby state that I have read, understood, and agree to the terms of this document.

Consent Form – Please Fill Out Completely

By signing you agree that all information is accurate and correct to the best of your knowledge and consent to being contacted by Collective Recovery Center.

Accepted Insurance Providers:

Collective Recovery Center
9543 S 700 E Suite 200, Sandy, Utah 84070


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