CONSENT FOR SERVICES

Teletherapy

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1. I understand that I wish to engage in a teletherapy live video consultation and/or Talk Time interaction online. I understand that licensed clinicians are bound by rules and regulations governing their state. I understand that Talk Time staff are not being advertised as a psychologist or counselor providing services that require license by appropriate jurisdiction. I understand that the activities of Talk Time staff under SEYLA Counseling, inc., are supervised by licensed clinical staff.

2. I understand that SEYLA Counseling, inc., has made every reasonable effort to enable HIPPA compliant protocols and Secure Web Browsing from available vendors.

3. I understand that video conferencing technology will be used to affect such consultation will not be the same as a direct patient/healthcare provider visit due to the fact that I will not be in the same room as my health care provider.

4. 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 telemedicine consultation if it is felt that videoconferencing connections are not adequate for the situation. In such case your session fees will be prorated.

5. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation process other than my health care provider and/or consulting health care provider in order to operate the video equipment. The above mentioned people will all maintain confidentiality of the information obtained and are present only in a technical service capacity requested by you, the user, to test the audio/video of your equipment.

6. I understand I may choose to see this health care provider in their office. I am opting to use telemedicine for my convenience. I understand some parts of the consultation requires the exchange of information with my other healthcare providers and/or family members. I will be given an opportunity to specify to whom, and for how long I give permission, and that I may revoke such permissions at will.

7. I understand that the responsibility of the telemedicine consulting specialist (e.g., our licensed clinicians as well as our Talk Time staff) will conclude upon the termination of the video conference connection.

8. I understand that if I present with an emergent circumstance, it is my responsibility to contact 911 and receive immediate help.

9. I understand that billing will occur from SEYLA Counseling through one of its billing vendors.

10. I understand the risks associated with teletherapy as outlined herein, and may present any concerns I may have. In such case that my concerns are not adequately addressed, section 4 above may apply.