Telehealth Consent & Technology Agreement

Client Name & Date of Birth

Acknowledgment of telehealth benefits, limitations, and privacy considerations: I understand the benefits and limitations of telehealth services, including possible technology or connection issues, and the privacy considerations involved, and I consent to receiving services via telehealth.

Confirmation Client will be Located in Florida During Telehealth Sessions

Yes

No

Preferred platform/technology access confirmed

Emergency Location & Contact During Sessions (address, local emergency contact name, & contact information)

Signature

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Date

Telehealth Consent & Technology Agreement