Informed Consent

I give my consent to Catherine Scholz and Lauren Elasik with the CIIS Group Therapy Project to only share my personal content and expressive artwork with their fellow students, supervisor and professors at the California Institute of Integral Studies for the purposes of learning. I understand that my personal information will be treated with the utmost respect and be kept confidential. After this group has commenced, the facilitators agree that all participant information will be deleted from this website and/or facilitator devices.

California law has long recognized telehealth as a form of delivery of health care and behavioral health services which many psychotherapists are practicing in the state of California and the rest of the United States. In California, “Telehealth” is defined as a method to deliver health care services using information and communication technologies to facilitate the diagnosis, consultation, treatment, and care management while the patient and provider are at two different sites. This form of service is usually live video conferencing through a personal computer with a webcam.

I hereby consent to engaging in telehealth with my counselor at CIIS Group Therapy Project as part of my psychotherapy. I understand that “telemedicine or telehealth” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that telehealth also involves the communication of my medical/mental information, both orally and visually, to health care practitioners located in California.

Because of recent advances in communication technology, the field of tele-therapy has evolved. It has allowed individuals who may not have local access to a mental health professional to use electronic means to receive services. Because it is relatively new, there is not a lot of research indicating that it is an effective means of receiving therapy. An important part of therapy is sitting face to face with an individual, where non-verbal communication (body signals) are readily available to both therapist and client. Without this information, tele-therapy may be slower to progress or less effective. With the telephone, the client’s tone of voice, pauses and choice of words become especially important and therefore an important focus of the sessions. I am aware that tele-therapy may or may not be as effective as in-person therapy.

In compliance with California law, all tele-therapy with a counselor at CIIS Group Therapy Project, Inc. must take place with the client located within the State of California. Counselors at CIIS Group Therapy Project, Inc. may not provide tele-therapy to clients located outside of California.

I understand that I have the following rights with respect to telehealth:

I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment or risking the loss or withdrawal of any benefits to which I would otherwise be entitled.
The laws that protect the confidentiality of my medical information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.
I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychotherapist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
I understand that telehealth based services and care may not be as complete as face-to-face services. I also understand that if my psychotherapist believes I would be better served by another form of psychotherapeutic services (e.g. face-to-face services) I will be referred to a psychotherapist 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 psychotherapist, my condition may not improve, and in some cases may even get worse.
I understand that I may benefit from telehealth, but that results cannot be guaranteed or assured.
I understand that I will follow my counselor’s recommendations for the setting, atmosphere, environment and other factors that will preserve my confidentiality and contribute to my ability to derive greatest benefit from tele-therapy.
I understand that if I am in need of emergency mental health services, feel suicidal or homicidal, I will call 911 and/or contact my local emergency room.
I understand that I have a right to access my medical information and copies of medical records in accordance with California law.
I will discuss with my psychotherapist any further questions I may have about tele-health until all of my questions have been answered to my satisfaction.
I agree to show up to sessions sober and not under the influence of illegal drugs or alcohol.
I agree to allow the facilitators to contact the person I listed as my emergency contact in the intake form in the case of emergency.

You may print a copy of this page for your records by using the print function in your browser.

Go back to the Intake Form

Questions? Contact Catherine