I understand that Telehealth means that I will be able to consult with a PWTH provider regarding mental/emotional/behavioral needs through an interactive electronic video connection, and my PWTH provider will be able to conduct sessions via such connection. The electronic software, systems, and equipment used to facilitate sessions will incorporate industry-standard and HIPAA-compliant network, software, and hardware security features and protocols to protect the confidentiality of my identity and PHI, and will include measures to safeguard data transmitted, as well as ensure its integrity against intentional or unintentional breach/corruption.

My provider and/or PWTH has explained to me how the Telehealth technology will be used for my
treatment and services if used at any point in time.

The benefits of Telehealth include, but are not limited to:

1. I may not need to travel to the session location.
2. I have improved access to my provider.
3. I have flexibility in scheduling around work, family, and other personal obligations.
4. I may receive more efficient services.

I understand there are potential risks with Telehealth may include:

1. The video connection may not work due to technical or connectivity issues, or that it may stop working during the consultation, resulting in delays in treatment.
2. The video picture or information transmitted may not be clear enough to be useful for the consultation, resulting in delays in treatment.
3. In very rare circumstances security protocols could fail, causing a breach of privacy or PHI.
4. I may be required to go to the location of the provider if it is felt that the information obtained via Telehealth was not sufficient to make a diagnosis, if state or federal regulations require an in- person session, or my physical presence is required to access further services.

I give my consent to utilization of Telehealth and being interviewed and/or seen for sessions by a mental health provider via Telehealth. I acknowledge that I have been adequately informed of Telehealth's risks
and benefits, and further understand that I have the right to ask my healthcare provider to discontinue use of Telehealth at any time.

I hereby release PWTH and its partnering providers and any other person participating in my care from any and all liability which may arise from the taking and authorized use of backups, data, videotapes, digital recordings, films, audio, and photographs.