TELECOUNSELING CONSENT FORM
Telecounseling is counseling provided via technology, which can include virtual/video consultations or other forms of data communications. I hereby give consent that Phileo Dynamix Counseling Services could provide telecounseling services to me.
Phileo Dynamix Counseling Services will protect the confidentiality of information as with face-to-face counseling. I understand that the information disclosed by me during the course of counseling is confidential. However there are both mandatory and permissive exceptions to confidentiality, which my counselor must legally adhere to. I hereby give consent that such information can be shared to the relevant professional/legal parties.
I understand that telecounseling communication could be complicated due to communication barriers such as possible poor quality audio video/feed, as well as limited non-verbal rapport building. I hereby acknowledge and accept these possible challenges as part of telecounseling.
I understand that telecounseling have some technological risks, including, but not limited to, the possibility, that the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorised persons; and/or electronic storage of my information could be accessed by unauthorised persons. There is also a risk that services could be disrupted or distorted by unforeseen technical problems.
I accept that Phileo Dynamix Counseling Services does not provide emergency services. If I am experiencing an emergency situation, I understand that I can proceed to the nearest hospital emergency room for help. I can also seek the assistance of twenty four hour emergency assistance (for example; Life Line or the suicide Hot line), in need. If this is the case, or becomes the case in the future, my counselor will recommend more appropriate services.
I am responsible for providing the necessary computer, cell phone, telecommunications equipment and internet access for my telecounselling sessions. I am also responsible for arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my session.
I will ensure that the telecounselling session is not recorded by me in any form.
I agree to make payment for each telecounselling session before commencement of the session per EFT (bank details on website) as per rates set out for cash patients, or give Phileo Dynamix Counseling Services permission to claim from my medical aid as per medical aid rate.
I hereby confirm that I have read, understood and agree to the information provided above regarding telecounselling.