CONSENT FORM

Telehealth Appointments

I provide Telehealth sessions through HIPAA-compliant platforms that offer a signed Business Associate Agreement (BAA). I follow the recommendations of the Board of Social Workers and all applicable state laws to protect your confidentiality. While no electronic method is ever 100% secure, I use updated encryption, firewalls, and secure systems to safeguard your information to the best of my ability.

Virtual appointments offer flexibility and can support our healing process. However, part of our ongoing therapeutic work will be assessing whether virtual connection continues to meet your innate need for presence, authenticity, and relational attunement. If we notice that Telehealth no longer supports this need, we will explore sustainable options in your community or transition to in-person care if available.

Technology Requirements & Preparation

Please prepare for our virtual sessions with intention:

• Choose a private, quiet, uninterrupted space.

• Use a stable internet connection and a device capable of audio and video (unless other arrangements are made).

• Avoid public Wi-Fi or shared devices whenever possible.
  
  

If the connection becomes unstable, I will attempt to reconnect once. If this is not possible, we will discuss whether to transition briefly to phone, reschedule, or make another plan. Repeated connection issues may be considered a cancellation.

Sessions Will Be Cancelled (with a $100 Fee) If:

• You are driving.
  I do not conduct sessions while a client is operating a vehicle. This endangers your safety and prevents meaningful therapeutic work.

• There are unannounced third parties present.
  If someone enters the session space unexpectedly, it breaches safety and confidentiality. If you’d like someone included, please tell me in advance.

In-Person Sessions & Liability
By attending in-person sessions, you acknowledge that therapeutic work carries some emotional and physical vulnerability. While I take reasonable precautions to maintain a safe and accessible environment, I cannot be held liable for accidents or injuries that may occur on the premises. You agree to take responsibility for your personal safety and to notify me of any medical, physical, or accessibility needs that may affect your care.

Emergency Procedures & Location Disclosure

Because Telehealth limits my ability to respond physically in an emergency, you agree to:

• Share your physical location at the start of each session.

• Provide a current emergency contact.

• Understand that if you are in crisis and unable to ensure your own safety, I may contact emergency services or your emergency contact.
  
  

Telehealth may not be sufficient for acute crises such as active suicidal intent, medical emergencies, or domestic violence emergencies. In these cases, I may recommend in-person or higher-level care.

Licensing & Location Restrictions

I can only provide psychotherapy services when you are physically located in states where I am licensed to practice. You agree to inform me of any change in your physical location before or during our session.

Confidentiality

I have a legal and ethical responsibility to protect all communications during Telehealth services. While I take every reasonable step to secure your information, electronic communication may be vulnerable to interception or unauthorized access.

You can support confidentiality by:

• Using secure networks

• Password-protecting your device

• Limiting who has access to your devices

• Using headphones for privacy
  
  

Client Rights

You have the right to:

• Withdraw or withhold consent for Telehealth at any time without affecting future treatment.

• Ask questions about Telehealth, treatment, risks, or alternatives at any point.

• Request copies of your clinical notes, treatment plan, or treatment summary at any time during or after treatment.

• Decline any modality or intervention that does not feel aligned with your needs.
  
  

Fees, Payment & Cancellation Policy

Payment

All fees are due at the time of service unless another agreement has been made.
Payment may be made by the methods you and I discuss during intake.

Cancellation Policy

Appointments must be cancelled at least 24 hours in advance or a $100 cancellation fee will be charged.

If you do not enter the session within 15 minutes, the session will be considered a no-show and the cancellation fee will be applied.

Email & Text Communication

I may contact you by text or email for:

• Scheduling

• Billing

• Appointment reminders or changes

• Psychoeducation or resources
  
  

You can revoke this consent at any time in writing. Text and email are not encrypted and carry risks, including possible interception or unauthorized access. I recommend deleting messages after you read them.

I do not provide clinical services, crisis support, or therapeutic processing via text or email.

Text/email communication may be made through:
awayuhealing@gmail.com
(856) 425-2733

Privacy Policy & Exceptions to Confidentiality

Your clinical information will not be released without your written consent except in the following cases required by law:

• Suspected abuse or neglect of a child, elder, or disabled person

• Serious risk of harm to yourself or others

• Court orders requiring release of records or testimony

• Professional consultation for clinical guidance (identifying information minimized whenever possible)
  
  

Case material may be used for training or academic purposes only after all identifying information is removed.

Recording Policy

Recording sessions (audio, video, screenshots) is not permitted unless we both provide explicit written consent.

Social Media Boundary

To protect your confidentiality and maintain the therapeutic relationship:

• I do not accept friend or follow requests from clients on my personal social media.

• You are welcome to follow @awayuhealing, but messages will not be responded to, as social media is not HIPAA compliant.

• Please use my website or email/text for communication.

Accessibility & Accommodations

If you require disability or language-related accommodations, please let me know. I will make every reasonable effort to support your access to care.

Acknowledgment & Agreement

I have read and understand the information provided above.
I understand the risks and benefits of Telehealth, the limits of confidentiality, my rights as a client, and all policies regarding payment and cancellations.
I agree to these terms and consent to treatment via Telehealth services with Awayu Healing LLC.