Advanced Behavioral Counseling of NNJ. LLC 55 Newton-Sparta Road, Newton, NJ 07860 CONSENT FOR TELEHEALTHClient Name* Date Of Birth* MM slash DD slash YYYY I understand the office of Advanced Behavioral Counseling, LLC is offering telehealth sessions due to the current health crisis surrounding COVID 19. ABC has explained to me how to utilize the HIPAA compliant synchronous platform technology, and that this format is not the same as direct client/clinician visit due to the fact that I will not be in the same physical space as my clinician. I understand that there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that ABC or I may discontinue the telehealth session if it is felt that the videoconferencing connections are not adequate for the situation. I understand that my healthcare information may be shared with other third parties for scheduling and billing purposes, as is the case for in-person sessions. I understand and agree that in order to preserve confidentiality, I will be in a private room with a closed door without any other individuals present in person or online. Only myself and my mental health clinician will be participating in the session unless it has been previously agreed to have a family session or other support person present. I also understand that clinician will need to know my location in the event of an emergency. I understand that if I am using a third-party payor such as health insurance, the plan will be billed and I will be responsible for the contracted rate towards the deductible, co-insurance, and/or co-pay. If I am not able to physically report to the office to present payment, I authorize ABC to charge the credit card on file, and that I have the ability to request an invoice for such payment. If I am not utilizing a third-party payor, I agree to pay the fee agreed upon with my clinician. I have had a direct conversation with clinician, during which I had the opportunity to ask questions in regard to telehealth sessions. My questions have been answered and the risks, benefits, and any practical alternatives have been discussed with me in a language in which I understand. By Signing this form, I certify: That I have read or had this form read and/or explained to me. That I fully understand its contents including the risks and benefits. That I have been given ample opportunity to ask questions and that the questions have been answered to my satisfaction. Client/Parent/Guardian Signature*Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.