Co-Parenting Solutions, LLC

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:

  1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.
  2. The laws that protect teletherapy discussed in detail in the general Co- Parenting Therapy Contracts.
  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 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.
  4. 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.
  5. 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

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Signature Certificate
Document name: 2. Authorization for Teletherapy
lock iconUnique Document ID: 21d117b768d71884628d77382c4bdff8becd6bfe
Timestamp Audit
July 24, 2020 11:35 am EDT2. Authorization for Teletherapy Uploaded by Jordana Wolfson - IP
August 18, 2020 10:09 am EDT Document owner has handed over this document to 2020-08-18 10:09:01 -