Telehealth Informed Consent
Telehealth (Also known as “telemedicine”, "online/web counseling”, or “remote services") allows Jeremiah Dieujuste, Licensed Marriage and Family Therapist #108065 in the state of California, to diagnose, consult, treat and educate using interactive audio, video or data communication in regards to my treatment. Thus, I hereby consent to participating in psychotherapy via video conferencing, or telephone, with Jeremiah Dieujuste.
Psychotherapy Services for California Residents ONLY
Jeremiah Dieujuste's policies and procedures comply with applicable state regulations. By engaging with Mr. Dieujuste, I understand that the services provided are licensed in the state of California only. I agree to the terms and conditions of the States of California and the services provided within the state of California. I agree and understand that the service I am receiving is psychotherapy therapy with a licensed psychotherapist within the state of California. If I reside outside of the state of California, I understand that it is not psychotherapy services, but rather a confidential consultation, psycho-education, coaching, or other wellness activities. Mr. Dieujuste holds responsibility only to the state in which he is licensed in and cannot be held accountable for any rules or regulations of other states outside of the state in which he resides and maintains an active license. I understand that I am receiving services at my own risk and hereby release Jeremiah Dieujuste from any legal ramifications should I injure myself in any way including, but not limited to physical, emotional, mental, or psychological distress or injury.
I, the client, understand that...
- I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any benefits to which I would otherwise be entitled.
- The laws that protect the confidentiality of my personal information also apply to online therapy with Telehealth. As such, the information disclosed to me during the course of my sessions 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 identifiable victim, and cases where I make my mental or emotional state an issue in a legal proceeding. Dissemination of any personally identifiable images or information from the Telehealth interaction to other entities shall not occur without my written consent.
- There are risks and consequences from the use of Telehealth online therapy including, but not limited to the possibility that the transmission of my personal information could be disrupted or distorted by technical failures despite reasonable efforts on the part of my therapist. That the transmission of my personal information could be interrupted by unauthorized persons. That the electronic storage of my personal information could be accessed by unauthorized persons.
- Telehealth online based services and care may not be as complete as face-to-face services. If my therapist believes I would be better served by another form of intervention (i.e. face-to-face services), I will be referred to a mental health professional who can provide such services in my area. Finally, 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.
- That I may benefit from Telehealth online psychotherapy, but that the results cannot be guaranteed or assured. There may be issues with Wi-Fi connectivity. All attempts to keep information confidential while using online communication will be made, but a guarantee of 100% confidentiality cannot be assured. By signing this form, it demonstrates my awareness of these issues. And if I choose to use Telehealth video conferencing, I will not hold my therapist liable for any gathering or use of client confidential information by Telehealth video conferencing providers.
- I have the right to access my personal information and copies of case records in accordance with California law.
- If I have chosen the option to receive services via Telehealth, I am aware that while my therapist ensures confidential meeting space on his end, I will need to ensure I have a space that is confidential wherever I choose to hold a session. By signing this agreement, I acknowledge that if I choose to have a session where another person(s) can hear me, then the breach of confidentiality is my choice and my therapist is not held liable for such a breach.
- I am consenting via written authority to allow contact with identified family and other treating professionals in my local area in case I need emergency backup, or in the event in which I am in need of services beyond the scope of Telehealth practice (i.e. hospitalization).
- If I have a mental health emergency, I will not wait for a call back from my therapist but, instead, I will contact once of the following emergency services:
Access Unit - Bilingual Spanish/TDD locations
1 (888) 743-1478
1 (888) 743-1481 [TDD]
Community Crisis Response Teams (CCRT)
(909) 458- 9628 (West Valley Region)
(909) 421- 9233 (East Valley Region)
(760) 956- 2345 (High Desert Region)
Crisis Walk-In Clinic - Rialto
850 E. Foothill Boulevard
Rialto, CA 92376
Ph: (909) 421-9495 • 7-1-1 for TTY for Users
Hours of Operation:
Monday-Friday 8:00 a.m. – 10:00 p.m.
Saturdays 8:00 a.m. – 5:00 p.m.
Crisis Walk-In Clinic - High Desert
Valley Star Behavioral Health, Inc.
12240 Hesperia Road
Victorville, CA 92395
Ph: (760) 245-8837 • 7-1-1 for TTY Users
Hours of Operation: 24 hours a day, 7 days a week