Life has changed radically this year.   We all want to get back to normal; shaking hands hanging out with friends, family and coworkers but until we can, let me help you through it.  We can utilize Telehealth or depending on the day with caution Face to Face sessions.  

Feel Like Yourself Again... or Better!


  1. I understand that my health care provider wishes me to engage in a telehealth consultation.  Telehealth allows me to stay at home and practice social distancing.
  2. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
  3. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
  4. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. 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.
  5. I understand that I will be responsible for any copayments or coinsurances that apply to my telehealth visit.   Coverage for telehealth varies by insurance company and I am responsible for confirming coverage with my insurance company and or for the cost of the session if not covered by insurance.
  6. Telehealth is NOT an Emergency Service and in the event of an emergency, I will use a phone to call the crisis hotline at 512-472-4357, Bluebonnet Trails Emergency after hours at 800-841-1255, Psychiatric Emergency Services at 512-454-3521, or go directly to the nearest hospital or call 911.  I can also text the crisis hotline at 741741.
  7. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.  Sessions will not be recorded by my therapist or by me the client.

Telehealth by Simple Practice is the primary technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. My therapist will email or text me a link to my appointment. 

I understand that during the Covid 19 Crisis my therapist is authorized to utilize other mediums to conduct telehealth sessions and to bill my health insurance company.   Not all health insurance companies cover telehealth.  In the event that internet signal is poor or we are unable to reasonably access Simple Practice Telehealth, my therapist may use alternative portals  Facetime, Audio phone calls, or Zoom. 

Please sign, date and return prior to session. _________________________________


I understand that I am opting for a face to face counseling session that is not urgent, instead of telehealth. I also understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and that social distancing is recommended. I hereby acknowledge and assume the risk of becoming infected with COVID-19 by choosing a face to face session.  I understand the potential risks and complications related to COVID-19.  I am aware that my therapist has put in place reasonable preventative measures aimed to reduce the spread of COVID-19.  I am aware that anyone at high risk; over the age of 65 or older and / or having pre-existing health conditions is recommended to avoid any non-essential contact.   I understand that if a face to face client of my therapist contracts COVID-19 that the Texas DSHS, CDC or authorized government agent may order my therapist to release my name and contact information only, for the purpose of CONTACT TRACING to help slow and contain the spread of the COVID-19 virus in Texas.

The Privacy Rule permits a covered entity to use and disclose PHI, with certain limits and protections, for TPO (treatment, payment and healthcare operations) activities [45 CFR § 164.506].

For disclosures not required by law, covered entities may still disclose, without authorization, to a public health authority authorized by law to collect or receive the information for the purpose of preventing or controlling disease, injury, or disability, the minimum necessary information to accomplish the intended public health purpose of the disclosure [45 CFR 164.512 (b)] (Box 1).

I assert that for any face to face session, I am not experiencing currently or within the past seven days:

Cough, Shortness of breath or difficulty breathing, Feeling feverish or having a temperature of 100.0 degrees or more, Loss of taste or smell, Chills, Repeated shaking with chills, Muscle pain, Headache, Sore throat, or Diarrhea.   

I have not traveled in the past 14 days to regions heavily effected by COVID-19.  I have not been in close contact with anyone diagnosed with COVID-19.  I have been practicing safe social distancing and thorough handwashing and / or hand sanitizing.

 Please Sign date and return prior to session. __________________________________