Distance Counseling, Telecounseling, Electronic Technology Consent Form
Dr. Karla Ivankovich, PhD, LCPC, NCC, BCPC, DCC
This Agreement and Consent Form for Distance Counseling, conducted by Dr. Karla Ivankovich is being provided to you (client) in order to inform you about Distance Counseling and answer some questions you may have. I understand that I must be at least 18 years of age to consent. As a client of Dr. Karla Ivankovich, I declare that Dr. Karla Ivankovich may be legally required to violate confidentiality to make appropriate legal notifications if they reasonably believe I am involved in child abuse or neglect or if I intend to harm myself or anyone else.
Distance Counseling Options Offered & Client Privacy:
I, the client, understand that Dr. Karla Ivankovich, or her respective staff currently offer distance counseling via phone and visual telecommunication. She offers these visual telecommunication options: Phone (land line or cell), or Skype. I fully understand that no form of distance counseling is a guaranteed format for client confidentiality. I understand that they can offer distance counseling via phone sessions and that telephone is not HIPPA protected.
I realize that I will be charged a pre-arranged fee for services according to Dr. Karla Ivankovich’s fee schedule for online counseling. We need to recognize that the process of Distance Counseling differs from in person counseling in that the full range of senses may not be readily expressible through electronic means. Dr. Karla Ivankovich does not guarantee resolution of any kind or assure success for online counseling, either explicit or implied.
In addition, as a client of Dr. Karla Ivankovich, I can end services at any time, for any reason, without prior notification or explanation, (Although notice explaining any decision to stop services would be greatly appreciated). Although Dr. Karla Ivankovich has taken significant steps to ensure the confidentiality and privacy of Online/ Distance communication, these actions, in whole or in part, cannot be 100% guaranteed due to the nature of internet transmissions. I permanently agree to release and indemnify Dr. Karla Ivankovich from all suits, claims, and other actions originating from psychotherapy provided through Distance Counseling.
Confidentiality and Distance Counseling
Clients are responsible for the confidentiality of their own environment. In face-to-face counseling, the counselor can do a fair amount to make changes to increase privacy in the therapeutic environment. This is not possible when doing distance counseling.
- The computer and all data has potential to contain confidential information;
- Be mindful of leaving a computer window open and moving away from the screen;
- Consider who may have (whether authorized or not) access to your information;
- Be aware of the possibility of key logging software, which can be used with or without your knowledge; It is recommended not to put your counselor’s e-mail in your address book so that you are less likely to accidentally send confidential information to the wrong person;
- E-mail is not typically confidential.
- Many other programs or applications may not be HIPAA compliant.
- Verbatim correspondence from client-counselor interactions should not be revealed publicly by the client.
As a client of Dr. Karla Ivankovich, I understand that Distance Counseling is generally provided utilizing technology and that there may be problems with Internet connectivity, which is the fault of neither Dr. Karla Ivankovich nor me. Internet availability may be limited or disrupted by things such as server maintenance, upgrades, or other problems (such as software or hardware malfunction) or natural or man-made disasters (such as terrorist acts, Internet viruses, and so forth). These types of problems are beyond the control of Dr. Karla Ivankovich and me (client). If something like this were to occur, any scheduled appointments would be re-scheduled. I, the client, do understand that in the event of a technology failure during a phone or visual telecommunication session immediate steps will be taken by the therapist to reconnect. Contact via email/text is the first backup step to failed phone and visual telecommunication reconnection. The therapist will repeatedly attempt to use these methods to contact me through the remaining session time (and I will do the same, as well). I, the client, will confirm receipt of successful contact. The compromised appointment will be rescheduled and, unless other arrangements are made, will be billed at the full rate.
I understand that in the event of an emotional emergency, and I cannot reach the counselors, I can follow this Emergency Plan:
- Call 911 or local emergency response team
- Go to the nearest emergency room
- Contact the local crisis center
- Contact Dr. Karla by having her paged: 312-527-6500
I, the client, agree to create an emergency plan of action for my therapist to follow which will be discussed at the first session.
Recording of Sessions:
I understand that Dr. Karla Ivankovich, and her representatives will not record my visual or phone sessions, unless there is an explicit written consent by me for reasons that clearly benefit my treatment.
I understand that I have the option to choose the methods of telecommunications
that I prefer and that I must “opt in”.
Check all that apply: Distance Counseling Using Visual Telecommunication:
I give my consent to use Skype for my distance counseling.
Distance Counseling Using Phone – My Consent:
I give my consent to use the telephone for my distance counseling.
- I have had ample opportunity to ask questions and receive clarification about these options and this policy.
- I will comply with the above plans set up to address the potential risks of distancing counseling and discuss any aspects that require my participation in the planning.
- I understand that I have the option to choose which telecommunication method(s) I prefer. I have “opted in” for the electronic technology that is acceptable to me at this time.
- I understand that I have the option to change my mind about any of my choices listed above and I will do so in writing.
- I do recognize the potential risk of compromise to my confidentiality by using phone or visual telecommunication.
- I wish to proceed knowing these risks.