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Telehealth Consent Form

Purpose:

The purpose of this form is to ensure that consent is collected from all our clients before Telehealth sessions commence and to ensure that all clients understand what Telehealth is, what their rights are and what to do if they no longer want to participate in Telehealth.

Policy:

  • Clients must sign this consent form before Telehealth sessions can commence.
  • Verbal consent should be gained at the commencement of each session.
  • The Practitioner is responsible for ensuring that the client's confidentiality is maintained and that they are not overheard by anyone within the space where they conduct telehealth sessions. If this is a risk due to factors outside the practitioner’s control, they must advise the client to gain consent before continuing the session.
  • The Practitioner is not to record phone or video calls without an additional consent form first being completed.
  • All devices, including computers, laptops, tablets, and mobile phones should only be accessible by using a password. An automated screensaver or screen lock should always be used and should activate if the device is unattended for a maximum of 5 minutes.
  • Playtonomy Pty Ltd client health records can be accessed by an appropriate team member when required. All client health records are electronic and accessible through Power Diary by appropriate employees/contractors.
  • This practice is considered primarily paperless and has systems in place to protect the privacy, security, quality and integrity of the personal health information held electronically. Appropriate employees/contractors are trained in computer security policies and procedures.

Procedure:

  • At the time of booking the appointment, the client must be informed that the appointment will be via Telehealth.
  • The client must sign the Telehealth Consent Form before the appointment.
  • If the client has not completed the form before the appointment, the clinician may gain verbal consent for the session.
  • Playtonomy Pty Ltd workers have different levels of digital access to client health information. To protect the security of health information, employees/contractors do not give their computer / Power Diary passwords to others in the team.

Telehealth Consent Form:

 

Telehealth Consent Form

 

I, , (parent/guardian’s full name) understand Playtonomy Pty Ltd.’s requirement to protect the privacy of information as detailed below.

All client records are to be kept strictly confidential and are inclusive of the below: 

  • Records of video and audio calls.
  • Clinical data and notes.
  • Accounts.
  • Verbal discussions.
  • Written documents (including those emanating from computers or facsimile machines and those heard).
  • Information provided that is written, received or otherwise produced by others or the therapist.

All client information is strictly private and confidential and is not to be discussed or in any way released to anyone except under instruction by the treating practitioner or designated privacy officer, and/or according to privacy law. 

Please sign below to acknowledge the above and to consent to our Telehealth Policies and Procedures:

Referral Form

WeTransfer Consent Form for Video Uploads

Therapist name: Millie Evans

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