Consent for Teletherapy

hereby consent to engage in teletherapy and/or telepsychiatry with Aspire Wellness Center, Inc. (“Aspire”).  I understand that “teletherapy” and “telepsychiatry” includes consultation, treatment, transfer of medical data, emails, telephone conversations and education using interactive audio, video, or data communications. I understand that teletherapy/telepsychiatry also involves the communication of my medical/mental information, both orally and visually. I understand that I have the following rights and responsibilities with respect to teletherapy and/or telepsychiatry:

Client's Rights
  • I have the right to withdraw consent at any time.
  • The same laws that protect the confidentiality of my protected health information also applies to teletherapy and/or telepsychiatry.  However, I understand there may be exceptions to total confidentiality which include: 
    • if the court orders release of records
    • if I present an immediate danger to myself or othersif abuse of children or special populations is suspected and
    • if health insurance requests information to authorize payment for services that I receive while at Aspire 
    These have been explained to me in such a way that I understand their contents. 

  • If you are required to attend treatment by a court order or other mandate, Aspire may be required to provide information such as attendance, notes, progress in treatment, and assessments/diagnostic information in response to a written request with a written authorization, court order, or legitimate subpoena. Aspire providers may be called to testify; however, it is at the discretion of the provider(s) whether recommendations for child custody cases or other legal issues are made. 
  • The parent or legal guardian of a minor has the right to access information regarding the minor’s care, excluding, for the most part, substance abuse or use information. Aspire may not release information to a parent or legal guardian, if the information may cause harm to the minor and it is found to be in the best interest of the child to not release the information. 
  • All treatment records will be kept for seven years as required by our overseeing boards (Maryland Board of Physicians, Social Work Examiners, and Professional Counselors and Therapists) and the Maryland Department of Mental Health and Hygiene. Following the seven years, records will be destroyed via shredding and disposal with a confidential recycling facility.
  • During accreditation or other audits or review, representatives from CARF International, DHMH, BHA, Beacon, or other payers may review client records for compliance with state or other standards and for accuracy. These reviews are held by the same confidentiality requirements as Aspire. 
Client’s Responsibilities
You have the responsibility to:
  • Keep and arrive on time for your scheduled appointments and, if unable to keep an appointment, to call the center and inform them of your inability to attend.
  • Pay the agreed upon fee for each treatment session.
  • Keep your therapist informed as to the major events and important issues in your life and rehabilitation.
  • Keep confidential any information you have regarding other patients at the center.
  • Follow the treatment plan that was mutually agreed upon between you and your therapist including the responsible use of medications and at program sponsored activities.
  • Conduct yourself in the appropriate manner in all program facilities.
  • Inform your therapist of intentions to leave treatment, and to discuss such termination before it is accomplished.
  • Treat the staff of Aspire with the same respect with which you would have them treat you.
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