Online Consent | Healing the Mind

Consent for Online Therapy

Thank you for your interest in engaging with online therapy.
The following sheet provides information about online therapy which will allow you to decide whether you want to consent to psychotherapy using this platform. Please feel free to ask any questions if you need clarification.

Benefits and limitations
Online therapy is a convenient alternative to traditional face-to-face therapy and has been shown to be effective in helping with many difficulties. However, online therapy has some limitations. There is a lack of “personal” face-to-face interaction which can make therapy less of a relational experience. It is also not an appropriate platform if you are seriously depressed, have serious substance dependence, or if you are experiencing intense suicidal or homicidal thoughts. Seeing a mental health professional face-to-face is recommended in these situations. Like most forms of psychotherapy, online therapy can make you feel worse before you start feeling better and the changes you experience may create conflict in your close relationships.

Technological requirements and competences
To engage in online therapy, you will require a device that can connect to the internet and be able to install and use the software that we agree on. A reliable high-speed internet connection (minimum 4Mbps for video) is also required. Please be aware that online therapy may utilize significant amounts of data, especially if video (300- 800MB/hour) is used.

Procedures for technical difficulties
Disruptions can occur when using the internet to communicate. Should our communication be disrupted, I will immediately attempt to reconnect and resume the session. However, if I am repeatedly unable to reconnect for a period of 10 minutes, the session will be rescheduled (via email).

Confidentiality
Any information provided to me will remain confidential and will not be given to a third party unless you give me specific permission to release the information. However, please be aware that if there is a significant risk of you seriously harming yourself or another person, I am obligated to act to prevent harm, which may involve giving information to a third party. Online therapy utilizes the Internet for the transmission of personal information and therefore there are increased risks to confidentiality and it can therefore not be guaranteed. To protect your confidentiality, I insist we use applications that provide encryption to communicate. Please consider password protecting the devices you use and installing antivirus software to prevent access by third parties. Please ensure that you use a private environment when engaging in online therapy so that intrusions can be minimized.

Crisis management
It can be difficult to deal with emergency crisis situations when using online therapy due to being in separate locations. I will therefore ask you to provide the contact details of a family member or friend as well as your medical practitioner whom can be contacted should the need arise. If you are in crisis and there is a disruption while we are engaging in online therapy, please phone me immediately.

Legal recourse
I am registered as a Counselling Psychologist (Registration No: PS 005 1802) with the Health Professions Council of South Africa (HPCSA) and my professional behaviour is governed by this regulatory body. Please note that if you are not located in South Africa any legal recourse will only be available in South Africa.

Billing
My services are billed by time and sessions are normally 60 minutes in duration. Invoices will be submitted your medical aid and sent to you via e-mail. Should your medical aid not settle the account, you will need to do so via electronic funds transfer. Please note that not all medical aids fund online therapy.

Consent

I have read the above and understand the risks associated with engaging in online therapy. I agree to participate in online therapy and comply with the policies outlined above.

I confirm that the following identifying details are correct:

First Name

Surname

Date of Birth

I agree that in the case of an emergency the following persons can be contacted for assistance:

Family / Friend Name

Tel Number

Medical Practitioner

Tel Number

Client Signature

Date

Signed at:

POPIA

“We shall process (collect, use, store and eventually delete or destroy) your personal information as per the Protection of Personal Information Act, No 4 of 2013 (as amended) (“POPIA”). By completing this form, you accept and agree that we may process, further process and share your personal information with our affiliates, partners or staff in order to render the services.”