CONSENT FOR TELEHEALTH CONSULTATION

This consent is being executed in conjunction with the use of the Platform, the Terms of Service and Terms of Use. I understand that my mental health care provider wishes me to engage in a telehealth consultation on the Platform. In that regard, I understand:

1. My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.

2. That a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

3. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

4. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

5. The Platform is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911 and the Platform does not provide any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.

6. The Platform facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.

7. I do not assume that my provider has access to any or all of the technical information on the Platform consultation or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the telehealth consultation through the Platform.

8. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

By signing this form, I certify: (i) that I have read or had this form read and/or had this form explained to me; (ii) that I fully understand its contents including the risks and benefits of the procedure(s); and (iii) that I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.