We require your consent to enable us to handle personal information about you and conduct your treatment. If you have any questions or concerns about this, please feel free to ask for a further explanation.
By completing the intake form and clicking yes to accepting the terms and conditions, you agree to the following:
(You understand that 'I' referred to below identifies you as the client)
I am not obligated to provide any information requested of me but that my failure to do so might compromise the quality and outcome of the health care and treatment given to me. My health records are confidential and case notes taken during my consultation are de-identified and stored on a secure server that is not accessible outside of Maggie Chilton.
Under no circumstances will my private information be disseminated or otherwise shared, unless legally requested via subpoena or police warrant.
I am aware of my right to access the information collected about me, except in rare circumstances where information may be withheld, and I understand that I will be given an appropriate explanation in these circumstances.
I consent to the sharing of my information with other practitioners of (Your Company Name) in a confidential manner in circumstances where it is deemed necessary to ensure a high standard of care.
My private information will not be shared with any persons or practitioners outside of Maggie Chilton without my prior consent in writing.
I understand and accept that the treatment provided by (Your Company Name) is not Guaranteed to heal/rehabilitate and there are no refunds provided once the program/session has commenced and total fee for the chosen program is payable. I release any liability on-site or on-site while under (Your Company Name)'s care, direction or advice and release (Your Company Name) from any liabilities such as overdose, death or injury incurred or claims to damages.
I acknowledge that I may be referred to another medical practitioner when my case exceeds the expertise or scope of practice of the practitioners within Maggie Chilton to ensure duty of care.
Teletherapy Waiver:
By completing the intake form and clicking yes to accepting the terms and conditions, you agree to the following; and hereby consent to engage in teletherapy with Maggie Chilton. And that agree and understand that 'I' referred to below identifies you as the client:
I understand that "teletherapy" includes consultation, treatment, transfer of medical data, emails, telephone conversations and education using interactive audio, video, or data communications.
I understand that teletherapy/coaching also involves the communication of my medical/mental information, both orally and visually. I understand that I have the following rights with respect to teletherapy:
I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.
The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy or consultation is generally confidential.
I understand that there are risks and consequences from teletherapy, including,but not limited to, the possibility, despite reasonable efforts on the part of (Your Company Name), 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 the electronic storage of my medical information could be accessed by unauthorized persons.
In addition, I understand that teletherapy based services and care may not be as complete as face- to-face services. I also understand that if (Your Company Name) believes I would be better served by another form of therapeutic services (e.g. face to-face services) I will be referred to a professional who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my therapist, my condition may not be improved, and in some cases may even get worse. and I understand that I may benefit from teletherapy, but that results cannot be guaranteed or assured.
I accept that teletherapy does not provide emergency services. During our first session, my allocated therapist and I will discuss an emergency response plan. If I am experiencing an emergency situation, I understand that I can call 000 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free 24 hour hotline support.
I understand that I am responsible for (1) providing the necessary computer,telecommunications equipment and internet access for my teletherapy sessions, (2) the information security on my computer, and (3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session.
I understand that while email may be used to communicate with (Your Company Name), confidentiality of emails cannot be guaranteed.
I understand that I have a right to access my medical information and copies of medical records in accordance with HIPAA privacy rules and applicable state law. I have read, understood and agreed with the information provided above.
Cancellation Policy:
I agree that any missed or rescheduled sessions without at least 24 hours notice will be forfeited without refund.
I agree that my session/program will not be able to be refunded once commenced.
