Name * First Name Last Name Date of birth MM DD YYYY Informed consent for telehealth treatment Please note that ongoing telehealth treatment with a North Carolina-licensed mental health clinician is generally not available if you are physically located outside of the state of North Carolina. At the start of your visit, your treating clinician will ask you for the address where you are receiving telehealth services in order to confirm that you are located in North Carolina and to ensure there is an accurate location for you in case of an emergency. Please note the following with respect to teletherapy services: You retain the option to withhold or withdraw consent at any time without affecting your right to future care or treatment. There are risks and benefits associated with teletherapy. Risks include disruption of electronic connection by technology failures, interruption and/or breach of confidentiality by unauthorized persons, and/or limitations on ability to respond to emergencies. Telehealth-based services and care may not yield the same results or be as effective as face-to-face service. If you or your treating clinician believes you would be better served by face-to-face service, you may be referred to a provider in your area to receive such service. If you are having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, or experiencing a mental health crisis that cannot be resolved via electronic communications, it may be determined that teletherapy services are not appropriate and a higher level of care is required. By engaging in telehealth services you agree there will be no recording of any teletherapy sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law. You agree to conduct the visit in a private space without any other attendees present, or able to hear or see your visit, unless an alternative arrangement is agreed to between yourself and your treating clinician. The visit will not take place while you are driving. Please sign below to acknowledge that you have reviewed this document and give your consent: Signature * Today's date * MM DD YYYY Thank you!