Telehealth Informed Consent

Online Therapy, also known as Telehealth, involves the use of electronic communications to enable mental health professionals to connect with individuals using interactive video and audio communications. Telehealth includes the delivery of psychotherapy, including diagnosis, consultation, treatment, and referral to resources, education, and the transfer of medical and clinical data. Should you have any questions, please contact us via email at support@renewalcenter.org.


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Rights, Benefits, and Risks

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

  1. Confidentiality: I have the right to keep my personal health information (PHI) private in Telehealth just as I do in face-to-face therapy.

  2. Rights: I understand that I have the right to withhold or withdraw my consent to the use of Telehealth in the course of my care at any time without affecting my right to future care or treatment and that my therapist has the right to accept or deny Telehealth as a valid venue for therapy in the best interest of my care.

  3. Benefits: I understand that I may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of Telehealth in my care, but that no results can be guaranteed or assured.

  4. Risks: I understand that there are risks and consequences from Telehealth including, but not limited to, the possibility of technical issues that are beyond our control, and that the transmission of my personal information could be disrupted or distorted by technical failures.

  5. Consequences: I understand that if I late cancel within 24-hours, do not answer the phone call of my therapist, or if I am not present at the video session at the time of the appointment, that I will be assessed a “No Show” which a $45 fee may be the result of my absence per our Financial Responsibility. I understand that it is my responsibility to provide the correct email and mobile number to set up any video conferencing software on my personal technology.

  6. Liabilities: I understand the alternatives to therapy through Telehealth as they have been explained to me, and in choosing to participate in Telehealth, I am agreeing to participate using video conferencing technology and/or telephone therapy. I understand that Renewal Center has contracted with HIPAA compliant technology services for Telehealth, but that there is still a minimal, inherent risk that the security of this technology may be compromised by hackers or other forms of outside influence. If it is found out that there has been a security breach, Renewal clients would be notified immediately.

  7. Crisis: I understand and agree that certain situations, including emergencies and crises, are inappropriate for audio/video computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 911 or seek help from a hospital or crisis facility in my area.

Payment for Telehealth Services

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Renewal Christian Counseling Center will bill your health insurance provider for Telehealth services when these services have been determined to be covered by an individual’s insurance plan. If your insurance is not accepted, the individual agrees to pay out-of-pocket.

Telehealth Consent

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This is a working agreement between yourself and Renewal Christian Counseling Center. By signing the Service Agreement , you are agreeing to the conditions of our program.


Sign the Agreement
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