Mental Health Telehealth Sessions

Telehealth Consent

What is Telehealth?

Telehealth utilizes technology to enable remote healthcare services. This encompasses a wide range of activities including medical and mental health diagnoses, treatment, therapy, follow-up care, and patient education. By proceeding with this form, you agree to participate in telehealth sessions with a mental health provider at DVH NP IN PSYCHIATRY SERVICES, PLLC.

Telehealth Agreement:

This agreement outlines the key points associated with telehealth services.

  1. Confidentiality: The privacy and confidentiality rules protecting your health information in face-to-face consultations remain applicable during telehealth services.
  2. Technical Requirements: Stable internet connectivity and certain software are prerequisites for telehealth sessions. Details will be provided separately.
  3. Service Quality: While we strive to maintain top-quality services, the experience of telehealth might be different from traditional in-person consultations due to technological limitations.
  4. Technical Difficulties: In the event of technical issues, you are advised to end and restart the session. If reconnection isn’t possible within ten minutes, use the provided contact details to reach the provider.
  5. Emergency Procedures: Your mental health provider (psychiatrist, psychiatric nurse practitioner, social worker, psychologist, and/or mental health counselor) may need to contact your emergency contact and/or appropriate authorities during a crisis.
  6. Limitations of Telehealth: Telehealth might not be suitable if you are having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, or undergoing a mental health crisis that cannot be resolved remotely. In such cases, a higher level of care may be necessary.
  7. Consent Withdrawal: You can withdraw consent at any time without affecting your right to future care, services, or benefits.
  8.  Mandatory Reporting: Providers are ethically and legally obligated to report certain incidents to appropriate authorities, as prescribed by law.
  9. Financial Agreement: Information concerning potential cost differences between telehealth and in person services, insurance coverage, and payment methods will be communicated separately.
  10. Consent for Minors: If the patient is under 18 years  of age, a parent or guardian’s consent for telehealth services is required.
  11. Consent Updates: This consent form may be updated periodically. Patients are responsible for reviewing and consenting to any updated versions before participating in future telehealth sessions.
  12. Professional Licensing and Regulation: DVH NP IN PSYCHIATRY SERVICES, PLLC agrees to adhere to state jurisdiction’s regulations.

Contact Information:

  1. Call: (347) 573-9479
  2. Fax: (347) 745-5913
  3. Post: DVH NP IN PSYCHIATRY SERVICES, PLLC, 1185 Avenue of the Americas, 3rd Floor, New York, NY 10036.
  4. Email: For assistance or to voice concerns, please reach us through the following channels:

This document acknowledges that you have been informed of your right to receive a paper copy of the Telehealth Consent Practices upon request. This policy is effective upon your review of this form and request for mental health treatment.

If a patient is not accepted for treatment at DVH NP IN PSYCHIATRY SERVICES, PLLC and has never been seen at DVH NP IN PSYCHIATRY SERVICES, PLLC before, all their Protected Health Information (PHI) will be deleted within 30 days.

Please note: It’s your responsibility, or the parent’s or legal guardian’s responsibility in the case of a minor, to ensure you fully understand the terms and conditions outlined in this Telehealth Consent form. If you have any questions or require further clarification, feel free to reach out to us through any of the provided contact details.