Please read the below thoroughly and complete the fields below. If you would like to retain a copy for your records, please print before you submit.

Jessica Kwerel, LPC, LCPC
petlossdc.com
jessica@petlossdc.com
(202) 642-2682

Distance Counseling Informed Consent Form

Distance counseling, also called telemedicine, telehealth, or online therapy, is defined as counseling using electronic, telephone or visual telecommunications.

I consent to engaging in distance counseling with Jessica Kwerel, LPC, LCPC as a part of the therapy process and my treatment goals. Distance counseling will occur through live video online platforms.

Jessica Kwerel offers distance counseling services in two ways. The first is through doxy.me, a secure live video online platform. This platform uses encrypted point-to-point connections as is HIPAA compliant. Jessica also offers distance counseling through Zoom, specifically HIPAA compliant for Healthcare professionals.

I understand that I may benefit from distant counseling services, but that results cannot be guaranteed or assured. All attempts to keep information confidential while using these systems will be made but a guarantee of 100% confidentiality cannot be made with inherent issues with these communication systems. I further understand that there are risks unique and specific to distance counseling, including but not limited to, the possibility that our therapy sessions could be disrupted or distorted by technical failures or could be interrupted or could be accessed by unauthorized persons.

By signing this document, I agree that certain situations including emergencies and crises are inappropriate for audio/video/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 911 or go to the nearest hospital or crisis facility. By signing this document, I understand that emergency situation may include thoughts about hurting or harming myself or others, if I am in a life threatening or emergency situation, and/or if I am abusing drugs or alcohol and are not safe. By signing this document, I acknowledge I have been told that if I feel suicidal, I am to call 911, local crisis agencies, or the National Suicide Hotline by dialing 988.

I have the right to withhold or remove consent at any time without affecting my right to future care or treatment. My signature below indicates that I have read this Agreement and agree to its terms.

esignature

Per the ESIGN Act, your esignature is legally binding. By signing your name electronically below, you are agreeing that your electronic signature (or esignature) is the legal equivalent of your manual signature.