telemedicine consent


Michelle Turbide, LICSW

27 Rye Circle
South Burlington, VT 05403



I ________________________ (name of client) hereby consent to engaging in telehealth with Michelle Turbide, LICSW. I understand that “telehealth” includes the practice of health care delivery, assessment, diagnosis, consultation, treatment, transfer of medical data, and psychoeducation using interactive audio, video, or data communications. I understand that, with my signed consent, telehealth may also involve the communication of my mental health information, both orally and visually, to other health care providers located in Vermont.

Technology: I understand that I will need to download an application and/or software to use this platform. I also need to have a broadband internet connection or a smart phone device with a good cellular connection at home or at the location deemed appropriate for services. I also understand that in case of technology failure, I may contact Michelle via phone to coordinate alternative methods of treatment.

Insurance and Fees: If you reside in the state of Vermont, telehealth services will be billed through your insurance provider just as if you were coming in to the office. At this time, I will not be able to provide services to you if you are out of state due to licensing issues.

Scheduling: I understand that scheduling is conducted through Michelle Turbide and is based on my provider’s normal office hours. Telehealth appointments are considered outpatient services and not intended as a substitute for emergency or crisis services. Crisis or mental health emergencies should be directed to the local county crisis line or by dialing 911.

Video/Audio Recording: Following legal and ethical guidelines, telehealth sessions will not be recorded. (Please see my office policy on this)

Confidentiality: I understand that 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 self or others. Michelle will use a HIPAA compliant platform to provide telehealth services to protect my privacy and confidentiality.

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

  1. I have the right to withdraw my consent at any time.
  2. I understand that there are risks and consequences associated with telehealth including,

    but not limited to the possibility that despite reasonable efforts on the part of my therapist, the transmission of my medical information could be disrupted or distorted by technical failures.

  3. I understand that I may benefit from telehealth but that results cannot be guaranteed or assured.
  4. I understand that I have a right to access my mental health information and copies of medical records in accordance with Vermont state law.

I have read and understand the information provided above. I have asked my therapist questions and had them answered to my satisfaction. My signature below indicates my informed and willful consent to treatment using a telehealth platform.

___________________________________ ______________ Client Signature Date

___________________________________ ______________ Parent/Guardian Signature Date

___________________________________ ______________ Provider’s Name and Signature Date

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