INFORMED CONSENT TO ONLINE TREATMENT
I have considered, understand, and agree to the risks, benefits,
and alternatives to the use of chat and/or email and other forms
of online communication in clinical work with my treatment provider,
Elizabeth Zelvin, LCSW, CASAC. I understand that every effort will be
made to maintain the confidentiality of our communications, including
but not limited to provision of secure chat room and secure storage
of both paper and electronic files according to professional standards.
I understand that I can choose to conduct email correspondence by regular
email or by secure email on request, and that Ms. Zelvin can guarantee the
confidentiality of secure email only on her end of the communication.
I understand that no communication on the Internet can be guaranteed
completely free from potential breach of confidentiality in transit by
hackers or Internet service providers or by others who had access to
the account or the computer. I TAKE FULL RESPONSIBILITY FOR THE SECURITY
OF TREATMENT RECORDS ON MY OWN COMPUTER AND IN MY OWN PHYSICAL LOCATION.
Ms. Zelvin will not be held liable for any breach of confidentiality regarding
electronic or paper records taking place on my end.
I have been informed of circumstances in which online counseling or
therapy is not the appropriate or most effective treatment. In the event
of a medical, psychiatric, or other situation requiring face to face
intervention, I understand that it is my responsibility to seek such help.
IF I AM CURRENTLY CONSIDERING OR THREATENING SUICIDE OR ANY FORM OF HARM TO MYSELF
OR OTHERS, I TAKE FULL RESPONSIBILITY FOR SEEKING APPROPRIATE HELP IMMEDIATELY
AND FOR ANY ACTION I MAY TAKE. I understand that information on nationwide
crisis intervention and help resources in the United States includes the
Ms. Zelvin has fully disclosed her professional credentials, which are available
on her website, along with links to the licensing and credentialing bodies involved.
She has made it clear that she is licensed for independent practice as a clinical
social worker in New York State and credentialed as an alcohol and substance abuse
counselor, also in New York State. If I reside outside New York State, I hereby
confirm that I consider our meetings to occur in cyberspace and that Ms. Zelvin
does not claim to be licensed or credentialed in my state or country of residence.
If my state of residence has laws regulating with whom I may seek counseling or
therapy online, I am responsible for informing myself and complying with such
laws. I accept full responsibility for my decision to work with Ms.Zelvin
under these conditions.
On making prepayment for your first chat or email session, please click on the link to email me the following confirmation of informed consent:
- Subject line: Type Informed Consent.
- In the body of the email: Type I have read, understand, and agree to the statement on Informed Consent regarding online counseling and therapy with Elizabeth Zelvin, LCSW, CASAC.
- Signature: Type your full name.