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Telehealth Consent - Advanced Behavioral Care Servies (ABCS)

Client Name *

Guardian Name (if applicable)

Date of Birth *

Program (Partial Care, IOP, OP)

Email Consent

My provider agrees to maintain my protected health information in accordance with the practices described in its notice of privacy practices.  This notice also describes my rights with respect to the use and disclosure of my protected health information.

I understand I have a right to review the notice of privacy practices prior to signing this Consent.   I acknowledge that I have been provided with a copy of my provider’s notice of privacy practices and I have been given an opportunity to review the notice of privacy practices prior to signing this Consent.  My provider reserves the right at any time to change the privacy practices described in the notice of privacy practices.  I understand that I can obtain a copy of the revised notice by accessing the website address of  or by requesting one at any future appointment.

The notice of privacy practices is also posted at each program address.

Restrictions, if any, agreed to by the provider regarding the use and disclosure of health information or instructions for alternate methods of communications: (please describe in the section below)

By agreeing, I acknowledge that Email and text messaging are not completely secure means of communication because these messages can be addressed to the wrong person or accessed improperly while in storage or during transmission.  required

Select an option

Please note any restrictions on the information you agree to have emailed. 

Telehealth Consent to Participate

I have been offered the opportunity to receive services through interactive, phone/web-based video and/or audio technology. I have been advised of the benefits and risks associated with this type of service, and have had the chance to address any concerns I might have regarding telepsychiatry services.


  • The opportunity to consult with a specialist in a timely manner.

  • Provision of care without having to travel.

  • Coordination of services


  • This service might not meet my needs and I may still have to see a provider in person.

  • There is a possibility of my health care information being intercepted through electronic means. 

I will get instructions on how the equipment works before I receive any services. My participation is voluntary and I may choose to end telehealth services at any time and request face-to-face service when it becomes available.  When I am receiving services using this technology, I am aware of who is present in the room at the other location. I have been informed that at no time will the telehealth sessions I receive be recorded or used for any other purpose.

The services I receive will become a part of my treatment record at ABCS. My providers will have access to mental health and/or substance abuse information about me. This consent DOES NOT REPLACE any other ABCS consent forms or releases of information that I may have signed.

I understand the above and agree to receive services through telehealth.

Select an option

Thanks for submitting!

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