Informed Consent for Complimentary Consultation

Nature of Telehealth Services

Through a secure, interactive video connection, I will consult with Provider regarding concerns about myself, my dependent minor child, student, client, or other individual under my care. Provider uses HIPAA-compliant platforms (Microsoft Teams or Healthie) for these consultations.

Potential Risks of Telehealth

I understand the following potential risks associated with telehealth technology:

• The video connection may fail to establish or may disconnect during the consultation.
• Video or audio quality may be insufficient for an effective consultation.
• If conducted in a non-private location, confidential health information may be overheard or observed by others.

Benefits of Telehealth

I acknowledge the following benefits:

• Elimination of travel requirements.
• Access to specialized consultation services.
• Convenience and flexibility in scheduling.

Scope and Limitations of Services

I understand and acknowledge that:

• This complimentary or reduced-cost consultation is for informational purposes only and does not constitute medical, clinical, or professional advice.
• No formal client-provider relationship exists or is being established through this consultation.
• Provider is not providing billable professional services during this consultation.
• Information discussed should not replace advice from a licensed professional in the relevant field.
• I am solely responsible for seeking appropriate professional guidance for my specific situation.
• Provider is not liable for actions taken or decisions made based on information provided during this consultation.

Mandatory Reporting Requirements

I understand that nothing in this agreement supersedes Provider's legal obligations regarding mandatory reporting, including but not limited to:

• Child abuse or neglect
• Elder abuse
• Threats of harm to self or others
• Any other situations required by law

Professional Ethics (If Applicable)

If this consultation involves professionals such as RBT®, BCBA®, BCaBA®, or BCBA-D®, I agree to adhere to applicable ethical requirements of my licensing board, including the BACB® Ethics Code for Behavior Analysts.

Scheduling and Cancellation Policy

• To modify a scheduled consultation, I will contact Provider by email, phone, or by using the cancel/reschedule link provided.
• For changes requested less than 24 hours before the scheduled consultation, I will contact Provider by phone at 619-367-6445. My failure to do so will result in a 30-day scheduling hold during which time I will not have the opportunity to schedule another complimentary consultation.

Consent

By proceeding to the booking page, I acknowledge that I have read and understood this document, including the risks and benefits of telehealth consultation. My questions regarding the procedure have been answered to my satisfaction. By booking and/or joining the telehealth consultation, I hereby consent to participate under the conditions described herein.