Telehealth Consent Form

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Telehealth Acknowledgment + Waiver

The Dempsey Centers is committed to improving the health and wellbeing of our clients. There are times when we may offer services remotely or virtually, meaning through the use of electronic or other virtual computer or software-based technology instead of in-person (“Virtual Services”). There is no requirement to use Virtual Services and Dempsey Centers clients are encouraged to choose and take advantage of the modality of services that is most fitting and beneficial for the client.


The offered benefits of Virtual Services include not having to travel and being able to avoid physical proximity to others (and thus minimizing potential exposure to the COVID-19 virus or other communicable diseases).
I have chosen to receive the following via Virtual Services:
By signing below, I am acknowledging the following regarding Virtual Services:

(1) Virtual Services are voluntary. I have the right to decline to participate in Virtual Services without affecting eligibility for or access to future sessions or resources.

(2) There are risks to participating in Virtual Services. For example, while Dempsey Centers uses platforms that provide some assurance of confidentiality and security; there cannot be a guarantee that the remote experience will be completely free from outside disruption. Dempsey Centers may monitor and implement steps, such as passwords for accessing the sessions, to help minimize risk of unauthorized access. However:
  • Confidentiality of identity may be undermined, by an unintended, unauthorized disclosure to non-participants of an identifiable image or sound of participants.

  • there is risk that the communication will not be as easy or natural;

  • the transmission of communications may be disrupted or distorted by technical failures;

  • your location may not afford you the same privacy as being in the Dempsey Centers office. We recommend that you find a private, quiet space where you will not be interrupted or distracted.

(3) There is not the same degree of oversight and assistance as being in person.

By signing below, I am waiving any claim against Dempsey Centers arising from my participation in the Virtual Services.
  • The Virtual Session may require physical activity or exertion on my part. I recognize and acknowledge that my participation involves risks which may be hazardous and may cause me physical or other damage, and that Dempsey Centers does not have control over safety measures that may be appropriate for me to apply remotely. For example, I understand that falls, accidents or other unanticipated incidents or injuries may occur.

  • I am voluntarily participating in the Virtual Services and am responsible for my own actions and safety. I understand that I should be participating from a safe and secure location, free from hazards.

Condition of Participation in Virtual Services:
  • I agree to respect and promote the confidentiality of other participants.

  • I am not permitted to take screenshots or record a Virtual Session.

By signing below, I am acknowledging that I have reviewed the above information. I am voluntarily participating in the offered Virtual Services.

By signing below, I am waiving any claim against Dempsey Centers related to the fact that the delivery of information is through Virtual Services and related to any injury or damage or loss I may sustain through my participation in the Virtual Services.

- Signatures Follow -

NOTE: SIGNATURE OF THIS DOCUMENT INCLUDES A WAIVER OF CLAIMS
Name(Required)
MM slash DD slash YYYY
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Parent or Authorized Representative Name (if applicable):
I understand that my typed name above will carry the same effect as my written signature(Required)