WP E-Signature by Approve Me - Sign Documents Using WordPress -

2. Authorization for Teletherapy

I, , hereby consent to engage in teletherapy with Jordana Wolfson, LMSW. I understand that “teletherapy” includes consultation, treatment, transfer of medical data, emails, telephone conversations and education using interactive audio, video, or data communications. I understand that teletherapy/coaching also involves the communication of my medical/mental information, both orally and visually.

As with all services provided through Co-Parenting Solutions, LLC, there shall be no audio and/or video- recordings of sessions.

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

I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.
The laws that protect teletherapy discussed in detail in the general Co- Parenting Therapy Contracts.
I understand that there are risks and consequences from teletherapy, including, but not limited to, the possibility, despite reasonable efforts on the part of Jordana Wolfson, LMSW, that: the transmission of my information could be disrupted or distorted by technical failures and the transmission of my information could be interrupted by unauthorized persons. If that takes place, the session will promptly be terminated and rescheduled for a different time.
I understand that I may benefit from teletherapy, but that results cannot be guaranteed or assured. I accept that teletherapy does not provide emergency services. If I am experiencing an emergency situation, I understand that I can call 911 or proceed to the nearest hospital emergency room for help.
I understand that I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my teletherapy sessions, (2) the information security on my computer, and (3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session.

I have read, understand and agree to the information provided above.

Date Signed:

Revised 2/2022

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

July 24, 2020 11:35 am EDT

2. Authorization for Teletherapy Uploaded by Jordana Wolfson - jordana@coparentingsolutionsllc.com IP 68.60.107.55

August 18, 2020 10:09 am EDT

Document owner michael@yourppl.com has handed over this document to jordana@coparentingsolutionsllc.com 2020-08-18 10:09:01 - 75.128.132.184