• CONSENT FOR TREATMENT AND TREATMENT LOCATION: I, the undersigned, consent for my child/myself (individual ‘Client” named above) to participate in Mental Health and/or Substance Abuse assessment and treatment through HEADS, LLC. I authorize services consistent with the level of needs per my assessment. I certify that I fully understand the treatment. I have been made aware of the purpose and structure of the program to which I am admitted and the expected length of time in treatment.

    I also consent for the following individuals/organizations to be involved in the treatment of the above-named client. I understand that these persons will need to have access to protected health information for the purpose of assessment, treatment and health care operations.
    1. Referral Source
    2. HEADS, LLC.

    Consent to Receive Telehealth Services

    -I consent for the individual named above to receiving behavioral health and/or substance abuse services via telehealth. I understand that the individual named will be receiving health care services through an interactive, secure, web-based platform through the internet.

    -I understand that I will be oriented to the equipment and process before the initiation of telehealth services. I understand that my child’s or my participation, at any time in telehealth, is voluntary and I may refuse to participate or decide to stop participation at any time. I understand that my refusal to participate or decision to stop will be documented in my medical record.

    -I understand that the privacy and confidentiality of individual named above will be protected at all times. I also understand that the likelihood of a videoconference being intercepted by an outsider is similar to the potential interception of a phone call. When I am receiving services via telehealth, I will be notified as to who is in the room at the remote site.

    -I understand that the health care providers at both my child’s/my location and the remote video site will have access to any relevant medical information about my child/me including any psychiatric and/or psychological information, alcohol and/or drug abuse, and mental health records.

    -I further consent for the sharing and use of information for medical care, research, and collaboration with treating & research clinicians.

    PRIVACY EXCEPTIONS: I, the undersigned, acknowledge that in some circumstances, HEADS, LLC. is required to report private information about your child or you. We have a duty to report suspicion of child abuse and neglect to the State of Florida. We have a duty to warn potential victims if we believe that their lives are in danger. Other exceptions to privacy are explained in the Privacy Notice.

    FUNDING AUTHORIZATION:  I authorize my funding agency to pay for services directly to HEADS, LLC.  I further understand that protected health information will need to be released to the above-named funding source in order to process claims and obtain reimbursement.

    -I understand that I may revoke consent for the above at any time; however, I cannot revoke consent for action that has already been taken. A copy of this release shall be valid as the original.

    -I have received a copy of the HEADS, LLC “Notice of Privacy Practices.” This Notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

    -I have received a copy of the Outreach Client Guide/My Rights which describes my rights and responsibilities, including whom to contact for complaints and grievances.

    I certify that I am either the legal custodian (biological or adoptive parent) of the child listed above or I have produced the following legal document naming me as the legal guardian of the child authorized to consent for mental health and/or medical care: Court order signed by a Judge or Notarized statement signed by the parent.


  • Definition of Services

    I, the undersigned, hereby consent to engage in teletherapy with HEADS, LLC. Teletherapy is a form of psychological service provided via internet technology, which can include consultation, treatment, transfer of medical data, emails, telephone conversations and/or education using interactive audio, video, or data communications. I also understand that teletherapy involves the communication of my medical/mental health information, both orally and/or visually.

    Teletherapy has the same purpose or intention as psychotherapy or psychological treatment sessions that are conducted in person. However, due to the nature of the technology used, I understand that teletherapy may be experienced somewhat differently than face-to-face treatment sessions.

    I understand that I have the following rights with respect to teletherapy:

    Client's Rights, Risks, and Responsibilities:

    1. I, the client, am a resident of Florida, and a Medicaid recipient.
    1. I, the client, have the right to withhold or withdraw consent at any time without affecting my right to future care or
    1. The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy or consultation is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, which are described in the general Consent Form I received at the start of my treatment with HEADS, LLC. .
    1. I understand that there are risks and consequences of participating in teletherapy, including, but not limited to, the possibility, despite best efforts to ensure high encryption and secure technology on the part of my psychologist, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized
    1. There is a risk that services could be disrupted or distorted by unforeseen technical In addition, I understand that teletherapy based services and care may not be as complete as face-to-face services. I also understand that if my psychologist believes I would be better served by another form of therapeutic services (e.g. face-to-face services) I will be referred to a professional who can provide such services in my area.
    1. I understand that I may benefit from teletherapy, but that results cannot be guaranteed or I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my psychologist, my condition may not improve, and in some cases may even get worse.
    1. In addition, I understand that teletherapy based services and care may not be as complete as face-to-face services. I also understand that if my psychologist believes I would be better served by another form of therapeutic services (e.g. face-to-face services) I will be referred to a professional who can provide such services in my
    1. I understand that I may benefit from teletherapy, but that results cannot be guaranteed or I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my psychologist, my condition may not improve, and in some cases may even get worse.
    1. I accept that teletherapy does not provide emergency services. If I am experiencing an emergency situation, I understand that I can call 911 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free 24 hour hotline support. Clients who are actively at risk of harm to self or others are not suitable for teletherapy services. If this is the case or becomes the case in future, my therapist will recommend more appropriate
    1. I understand that there is a risk of being overheard by anyone near me if I am not in a private room while participating in teletherapy. I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my teletherapy sessions, and (2) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session. It is the responsibility of the treatment provider to do the same on their
    1. I understand that dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my written consent.
    1. If the client is a minor I, as legal guardian signing below, agree to be readily available in the location where the teletherapy session is conducted and to have my phone on my person at all times in the event of an emergency.

    I have read, understand and agree to the information provided above regarding receiving telemedicine services from HEADS, LLC: