Altignis Health LLC dba Mindfuli (“Company,” or “We,” or “Us,” or “Mindfuli,”), will utilize teletherapy as a component of any websites, softwares, accounts or applications (collectively, “Mindfuli,” or “Mindfuli Services,” or “Mindfuli Platforms,” or “Platforms,” or “Products“) for individuals actively registered for the applicable tiers of service offering clinical services, which can be referenced at www.mindfuli.com. For the purpose of the services provided by Mindfuli personnel including its clinical professionals, officers, agents, employees, and volunteers (collectively, “Service Providers“), “teletherapy” (collectively, “Teletherapy,” or “Telehealth“) means the use of synchronous (occurring at the same time) telecommunications technology or asynchronous (not occurring at the same time) telecommunications technology for provision of clinical therapeutic services. For the purpose of the services provided under Mindfuli and by its service providers, services may include, but are not limited to, assessment, diagnosis, consultation, treatment, counseling; transfer of clinical data; client clinical and professional education; public health services; and health administration.
By clicking “I ACCEPT” on this form, I acknowledge that I understand the following:
- I understand that the laws that protect privacy and the confidentiality of medical and/or clinical information that I may disclose to a service provider also apply to teletherapy, and that no information obtained or used to provide services will be disclosed without my explicit authorization.
- I understand that I have the right to withhold or withdraw my consent to the use of teletherapy during my care at any time, without affecting my right to future care or treatment.
- I understand that it is my obligation to notify my service provider(s) of my location at the beginning of each session. If for some reason, I change locations during the session, it is my obligation to notify my service provider(s)of the change in location.
- I understand that it is my obligation to notify my service provider(s) of any other persons in the location, either on or off camera and who can hear or see the session. I understand that I am responsible to ensure privacy at my location. I will notify my service provider(s) at the outset of each session and am aware that confidential information may be discussed.
- I understand that it is my obligation to ensure that any virtual assistant artificial intelligence devices, including but not limited to Alexa or Echo, will be disabled or will not be in the location where information can be heard.
- I agree that I will not record either through audio or video any of the session, unless I notify my service provider(s), and this is agreed upon.
- I understand there are potential risks to using teletherapy technology, including but not limited to, interruptions, unauthorized access, and technical difficulties. I understand some of these technological challenges include issues with software, hardware, and internet connection which may result in interruption.
- I understand that my service provider(s) is/are not responsible for any technological problems of which my provider has no control over. I further understand that my provider does not guarantee that technology will be available or work as expected.
- I understand that I am responsible for information security on my device, including but not limited to, computer, tablet, or phone, and in my own location.
- To maintain confidentiality, I will not share my teletherapy appointment link or information with anyone not authorized to attend the session.
- I understand that my service provider(s) or I (or, if applicable, my guardian), can discontinue the teletherapy session if it is determined by either me or my service provider(s) that the videoconferencing connections or protections are not adequate for the situation.
- I understand that I have the right to inspect all information obtained and recorded during a teletherapy interaction and may receive copies of this information for a reasonable fee.
- I understand that teletherapy may involve electronic communication of my personal information to other service providers who may be in other areas, including out of state. I understand that I will be required to provide my consent and hereby do so for forwarding information to other service providers. I understand that said personal information may be constituted of my personal medical or clinical information which I have disclosed via a teletherapy session or corresponding account, website, application, or platform.
- I understand that I may expect the anticipated benefits from the use of teletherapy in my care, but that no results can be guaranteed or assured.
- I understand that teletherapy service is NOT an emergency service. In the event of an emergency, I will use a phone to call 9-1-1 and/or other appropriate emergency contact.
- I recognize my service provider(s) may need to notify emergency personnel in the event he/she/they feels there is a safety concern, including but not limited to, a risk to self/others or my provider is concerned that immediate medical attention is needed.
- I recognize that my service provider(s) may need to notify local emergency services and/or protective services in order to comply with local, state, and national laws regarding Mandated Reporting.
- I understand that Insurance or other managed care providers may not cover teleservice sessions. I understand that if my insurance, HMO, third-party payor, or other managed care provider do not cover the Telehealth / Teletherapy sessions, I will be solely responsible for the entire fee of the session.
- I understand the my service provider(s) may include clinicians holding a license or associates and, if the latter, will be providing services under the direct clinical supervision of a qualified clinical professional.
USER CONSENT TO THE USE OF TELETHERAPY
By clicking “I ACCEPT,” the User affirms and asserts that he/she/they have read and understood the terms and conditions of this Informed Consent for Teletherapy in full, have discussed it with their service provider, and hereby consents to the use of teletherapy in accordance with the above.