Consent Form — Telehealth template

1. Nature of Telehealth

• Telehealth involves the delivery of services remotely using secure video or telephone technology instead of in-person contact. It allows for consultation, assessment, and ongoing support without requiring attendance at a physical location.

2. Technology and Limitations

• I understand that technical issues (poor connection, dropped calls) may occasionally interrupt sessions, and that remote delivery has limitations compared with in-person care, including reduced ability to observe non-verbal cues or respond to emergencies.

3. Privacy and Setting

• I agree to participate from a private, quiet location where I will not be overheard, and understand my provider will do the same. Sessions are not recorded unless both parties agree in writing.

4. Confidentiality and Data Security

• Sessions are conducted using encrypted, secure platforms where possible. Personal data is handled under the UK GDPR and Data Protection Act 2018. No method of electronic communication is completely secure, and I accept this inherent risk.

5. Emergency Procedures

• Telehealth is not appropriate for emergencies. In case of a medical or safety emergency during a session, I should contact local emergency services (999) or attend my nearest A&E immediately.

Client Information

• Full NameText
• Location During SessionsText
• PhoneText
• EmailText

Provider Information

• Provider NameText
• Licence No.Text

Emergency Contact

• Contact NameText
• Relationship / PhoneText

Acknowledgment and Signature

• Client SignatureSignature
• Date signed (client)Date
• Provider SignatureSignature
• Date signed (provider)Date

• By signing below, I confirm I understand and accept the terms of telehealth service delivery described above.