To ensure that each client seeking telehealth services understands what telehealth is, this notice will disclose the benefits, and possible risks associated with it. Once you have had the opportunity to review this telehealth informed consent, I will ask you to verbally consent to receiving telehealth services. Verbal consent for each telehealth episode is obtained and documented in the electronic health record. I use My Clients Plus for records, planning, scheduling, billing, and telehealth services via videoconferencing.


What is Telehealth?

Telehealth is a virtual consult between you, the client and the telehealth certified psychotherapy provider via telephone or video. Telehealth is provided through My Clients Plus, a HIPAA and CFR 42 compliant, secure program. It involves the delivery of services using electronic communications, information technology or other means between a therapist and client who are not in the same physical location. Telehealth may be used for intake, assessment, diagnosis, treatment, follow-up and/or patient education, and may include, but is not limited to, one or more of the following: electronic transmission of medical records, photo images, personal health information or other data between a patient and a healthcare provider; interactions between a patient and healthcare provider via audio, video and/or data communications; and use of output data from sound and video files. The electronic systems used in the telehealth service will incorporate network and security protocols to protect the privacy and security of your information and will include measures to safeguard data to ensure its integrity against intentional or unintentional corruption.


Anticipated Benefits

The use of telehealth service may have the following possible benefits: easier and more efficient for you to access services and treatment; allowing you to obtain services and treatment by a therapist in the comfort of your home; adhering to the VT Dept. of Health and CDC guidelines for reducing the spread of infectious diseases.


Possible Risks

While the use of telehealth can provide potential benefits for you, there are also potential risks associated with the use of telehealth. These risks include, but may not be limited to the following: the information transmitted may not be sufficient to allow for appropriate clinical assessment and decision making by the therapist; limits the ability of the therapist to conduct certain assessments and may in some cases prevent the clinician from providing a diagnosis or treatment plan, or from identifying the need for emergency interventions or treatment for you; the therapist may not be able to provide services for your particular condition and you may be required to seek alternative healthcare or emergency care services; delays in evaluation/treatment could occur due to failures of the technology or electronic equipment used; the electronic systems or other security protocols or safeguards used could fail, causing a breach of privacy of your protected health information or other information; given regulatory requirements, the diagnosis and/or treatment options, especially pertaining to certain interventions, may be limited.



1. Until further notice, all services you receive from the therapist will be provided using telehealth. This may include photographs and/or other images you submit through the telehealth system. The therapist will follow all recommended VT Dept. of Health and CDC guidelines for safe distancing protocols when deciding on whether to conduct in-person sessions.

2. No potential benefits from the use of telehealth or specific results can be guaranteed. Your concerns may not be addressed, your health may not improve and, in some cases, may get worse.

3.  You understand that it is your duty to provide the therapist truthful, accurate and complete information, including all relevant information regarding therapy or counseling services that you may have received or may be receiving from other providers.

4. You understand that your therapist may determine at their sole discretion that your condition is not suitable for diagnosis and/or treatment using the telehealth service, and you may need to seek in-person services and treatment.

5. For providers who accept assignment, I hereby authorize any insurance carrier with whom I have a policy to pay directly to that provider any benefits of any policies of insurance to those providers who have rendered services to me and who accept such assignment. I agree to pay all charges that are not paid in full by assigned insurance.

I hereby give my oral consent for James P Fitzgerald, MS (Psychotherapy) to provide consultation, intake, assessment, diagnosis, treatment plan collaboration, and therapy sessions via telehealth.