Telehealth Informed Consent Form​

I​, __________________________________, hereby  consent  to  engaging  in teletherapy with my existing therapist at Renewing Hope Family Counseling Center, Inc. I understand that “teletherapy” includes the practice of mental health care delivery, diagnosis, consultation, treatment, transfer of medical data,  and education using interactive audio, video, or data communications. I understand that teletherapy also involves the communication of my medical/mental information, both orally  and  visually,  to  Renewing Hope Family Counseling Center, Inc. via the teletherapy service, Doxy.me (a HIPAA compliant video platform service).

 

I understand that I have the following rights with respect to teletherapy:

 

(1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

(2) The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.

I also understand that the dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my written consent.

(3) I understand that there are risks and consequences from teletherapy, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychotherapist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons (e.g. hacking); and/or the electronic storage of my medical information could be accessed by unauthorized persons.

In addition, I understand that teletherapy based services and care may not be as complete as face-to-face services. I also understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my psychotherapist, my condition may not be improve, and in some cases may even get worse.

(4) I understand that I may benefit from teletherapy, but that results cannot be guaranteed or assured.

(5) I understand that I have a right to access my medical information and copies of medical records in accordance with California law.

(6) I understand that, per the ethical guidelines of the state of California, teletherapy services can ONLY be provided to those residing in the state of California at the time of service. 

(7) I also understand that teletherapy is not always a covered service by my insurance plan, and it is my responsibility to check with my individual plan to determine if teletherapy is authorized. The patient will ultimately be responsible for all fees related to teletherapy that insurance does not cover. 

(8) Teletherapy will be billed at the same rate of individual therapy services. 

(9) Teletherapy is a temporary service that is being offered to all Renewing Hope Family Counseling Center, Inc. clients due to extreme circumstances as a precautionary measure. Once these circumstances abate, therapy sessions will return to in-person services as previously scheduled.

 

Please contact 951-465-3664 directly if you have any questions. 

 

 

I have read and understand the information provided above. I have discussed it with my psychotherapist, and all of my questions have been answered to my satisfaction.

Our Therapists

Cassondra Marie Rose

Licensed Marriage and Family Therapist,

Lic # 87026, President

Licensed Marriage and Family Therapist,

Lic # 99929, Clinical Supervisor -Spanish

Maya Yvette Barnett

Licensed Marriage and Family Therapist,

LMFT # 110873

Tara Hawkins

Licensed Psychologist,

Lic # 30703

Paul James Lorona

Licensed Marriage and Family Therapist,

LMFT # 80000

Jose Ventura Campos

Licensed Clinical Social Worker,

LCSW # 92977

Anne Victoria Brazdzionis

Licensed Practical Clinical Counselor, Lic # 7123

Andres Hoyo

Licensed Marriage and Family Therapist,

LMFT #124638

Mercedes Borrayo

Licensed Marriage and Family Therapist,

Lic. #81029 Spanish

Lori Reynolds

Licensed Family Marriage and Family Therapist,

Associate Supervisor,

Lic #103567

Weeda Nawabi

Jackeline Guzman Gonzales

Associate Marriage and Family Therapist,

Lic # 112346

Supervised By: Leticia Sarinana, Lic # 99929

Associate Marriage and Family Therapist,

Lic # 280066

Supervised By: Leticia Sarinana, Lic # 99929

Romyna Astrid Becker

Associate Clinical Social Worker,

Lic# 77798

Supervised By: Leticia Sarinana, Lic # 99929

Brianna Ramming

Licensed Marriage and Family Therapist, Lic. 107405

Charissa Walker

Jessica Anita Balderas

Licensed Marriage and Family Therapist #118509

Associate Marriage and Family Therapist

Lic# 120438

Supervised By: Leticia Sarinana, Lic # 99929

Cheng Yang Hsiao (Jeff)

Associate Marriage and Family Therapist,

Lic # 119527

Supervised By Leticia Sarinana, Lic # 99929

Fresvinda Chue

Licensed Marriage and Family Therapist,

Lic. #121001

Laura Gutierrez

Associate Marriage and Family Therapist,

Lic # 122169

Supervised By Lori Reynolds, Lic #103567

Briana Nicole Henry

Licensed Marriage and Family Therapist, Lic # 104847

Andrew David Gonzalez

Licensed Marriage and Family Therapist,

Lic # 12441

Lynda Carraway

Associate Marriage and Family Therapist,

Lic # 94451

Supervised By Lori Reynolds, Lic. #103567

Eric Alejandro Maldonado

Associate Marriage and Family Therapist,

Lic. #122401

Supervised by Cassondra Marie Rose, Lic. 80726

Lihle Ntombifikile Adeyemi

Associate Marriage and Family Therapist,

Lic. #121223

Supervised By Lori Reynolds, Lic. #103567

Alanna Marie Villanueva

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Lauren Marie

DeMenezes

Psychiatry Appt

Corinna Marie

Cabral

Associate Clinical Social Worker,

Lic. #90181

Supervised By Leticia Sarinana, Lic #99929

Yobana Munoz

Associate Marriage and Family Therapist

Lic. #113528

Supervised By Leticia Sarinana, Lic #99929

Associate Marriage and Family Therapist,

Lic. #106646

Supervised By Leticia Sarinana, Lic #99929

Associate Clinical Social Worker

Lic. #89610

Supervised By Leticia Sarinana, Lic #99929

Jacqueline Gonzalez

Associate Marriage and Family Therapist

Lic. #113958

Supervised By Leticia Sarinana, Lic #99929

Farshid Yadegar

Psychologist

Lic. # 22681