Online Therapy Consent

2/6/2020

Online Therapy Consent

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

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 bene ts to which I
would otherwise be entitled.

2. The laws that protect the con dentiality of my medical information also apply to
telemedicine. As such, I understand that the information disclosed by me during the course of
my therapy is generally con dential. However, there are both mandatory and permissive
exceptions to con dentiality, 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. 

Consent: Signature
Option 1

Full Name
Liv Wisham

Birth Date Email

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Address
785 Hudson Center, 4689 Meadow Ridge Parkway
Cleveland, Ohio, 44111
United States
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Phone Number
+15 (31) 279-5545

Submission ID 394569970587811454 Submission Date 2/6/2020

3

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