This form provides information about receiving psychotherapy services through telehealth (video-based mental health services). Please read carefully.

1. What Is Telehealth?

Telehealth is the delivery of mental health services using secure online video platforms. This form of care may be used instead of, or in addition to, in-person sessions.

Inner Peace & Enlightenment Therapy provides telehealth-only services.

Telehealth allows the therapist and client to communicate in real time for assessment, therapy, consultation, and treatment planning.

2. Client Location Requirement (Required by Virginia Law)

Because your therapist is licensed in the Commonwealth of Virginia, you must physically be in Virginia at the time of each session.

You will be asked to verbally confirm your location at every telehealth appointment. If you are not located in Virginia, the session will be rescheduled.

3. Technology Requirements

You agree to:

• Use a secure, private location for sessions
• Use a device with a working camera and microphone
• Maintain a stable and reliable internet connection
• Prevent unauthorized persons from overhearing or viewing sessions
• Ensure your device and software are up-to-date

The therapist may refuse or pause a session if privacy cannot be ensured.

4. Risks of Telehealth

Telehealth has risks, including:

• Poor internet connection or dropped calls
• Delays or distortions in audio or video
• Limited ability to observe nonverbal cues
• Possible technical failures resulting in incomplete sessions
• Increased potential for privacy breaches on the client's side

If a session is interrupted, your therapist will attempt to reconnect. If reconnection is not possible, the session may be rescheduled.

5. Benefits of Telehealth

Telehealth may offer:

• Increased access to care
• Reduced travel time and cost
• Greater scheduling flexibility
• Continuity of care during illness or transportation issues

6. Confidentiality & Privacy

Confidentiality laws and HIPAA regulations apply to telehealth services.

Your therapist agrees to:

• Use HIPAA-compliant telehealth technology
• Provide services from a private, secure location
• Maintain confidentiality of all session content

You agree to:

• Maintain privacy on your end
• Ensure no one is recording or viewing the session
• Avoid participating in sessions while driving or in unsafe environments

Recording Prohibition

Sessions may not be recorded by either party without written consent from both client and therapist.

7. Emergency Procedures (Required for Telehealth)

Because your therapist cannot provide physical assistance in an emergency, you agree to:

• Provide your current physical address at the start of each session
• Keep an accessible phone available during sessions
• Call 911, Emergency Services, or go to the nearest Emergency Room if you are in immediate danger

Your therapist may work with you to create a safety plan if needed. If your therapist believes you are in immediate danger and cannot reach you, they may contact emergency services.

8. Appropriateness of Telehealth

Telehealth may not be appropriate for all presenting concerns. Your therapist may determine that an in-person or higher level of care is necessary and will provide referrals if this occurs.

9. Limits to Telehealth Services

Your therapist:

• Cannot guarantee immediate availability
• Does not provide 24-hour crisis services
• Cannot provide telehealth sessions if you are outside Virginia
• Does not conduct therapy through text or email
• May require an in-person or emergency evaluation if clinically necessary

10. Consent to Telehealth Services

By signing below, you acknowledge and agree that:

• You understand the risks, benefits, and limitations of telehealth
• You agree to receive treatment via telehealth
• You understand you must be physically located in Virginia during sessions
• You understand emergency procedures
• You have had the opportunity to ask questions
• You may withdraw consent for telehealth at any time (except where prohibited by your plan or during emergencies)