Please read the following policies carefully. Your signature at the end is an indication of your acceptance of the terms.
CONSENT FOR TELEHEALTH SERVICES
1. I understand that Your Sexuality Matters provides telehealth services only.
2. I understand that video conferencing is not the same as in-person services given that I will not be in the same space as my provider.
3. I understand that there are potential technological challenges that might develop, including interruptions, unauthorized access, and technical difficulties.
4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties, I understand that my clinician or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
5. I understand that I have the opportunity to ask questions in regard to telehealth including the risks, benefits, and any other practical alternatives.
6. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend my appointments.
7. I agree that for my safety I will not under any circumstance, .engage in telehealth services while driving. On occasions when I am engaged in telehealth services outside of an enclosed space, I acknowledge it as my responsibility to ensure that my surroundings are safe.
ATTENDANCE
Regular attendance at scheduled sessions is expected, and is vital to you having greatest benefit from the process, and to a successful treatment.
PAYMENT
Payment for services is due prior to the scheduled start of each session, and is scheduled through PayPal. As a client you are fully responsible for the payment of all services provided. Your rate is the dollar amount that is agreed on during our initial contact (phone or email) and is subject to change depending on demand, and cost of doing business.
CANCELLATION
There is a standard policy that requires 24 hours cancellation notice. If less than 24 hours' notice is provided, there will be a charge for half of the scheduled fee. If the client(s) fails to show for the appointment, there will be a charge for the full fee, unless the appointment is rescheduled in the same week. exceptions may be made at the discretion of the clinician in cases of emergency.
CONFIDENTIALITY
All information obtained, generated, or documented in the course of providing counseling is held in confidence by YOUR SEXUALITY MATTERS staff, with the following exceptions:
a. Threat of serious harm to self or others
b. Reasonable suspicion of child abuse, or neglect or abuse of a child, exploitation of an incapacitated or dependent adult
c. Court order
d. Voluntary release signed by client
e. Consultation with other professionals, as consented to by client.
SOCIAL MEDIA/INTERNET BOUNDARY
Confidentiality and the maintenance of professional boundaries are critical in the delivery of services. This is ensured by clinicians having no social contact with clients outside of the designated session, or on any social media site. Beyond the initial search which clients undertake to identify a provider, any other internet search will be considered stalking.
CLIENT CONSENT TO TREATMENT
I have read all of the above information and fully understand it. I consent to counseling with the staff of YOUR SEXUALITY MATTERS under the terms described above, and recognize that I have the right to terminate counseling at any time. My signature below is an acknowledgement that I have read and agree to the Consent for Telehealth, Attendance, Payment, Cancellation, Confidentiality, and Social Media and Internet Boundary policies above.