This form describes telehealth services offered by Celimot and asks for your informed consent to receive care through this format. Please read carefully and ask any questions before your first consultation.
What Is Telehealth?
Telehealth is the delivery of healthcare services using video conferencing technology, allowing you to consult with your provider remotely rather than in person.
Benefits of Telehealth
Access to care without travel or in-person waiting
Convenient scheduling, including same-day availability
Continuity of care for follow-up and medication management
Risks and Limitations of Telehealth
By consenting to telehealth services, you understand and acknowledge that:
Technology can fail. Poor internet connection, audio/video interruptions, or technical malfunctions may delay or disrupt a session.
Physical examination is limited. Your provider cannot perform an in-person physical exam via video, which may affect assessment or diagnosis in some cases.
Confidentiality, while protected, carries some inherent risk. As with any electronic communication, there is a small risk that information transmitted could be intercepted or accessed by unauthorized parties, despite our security safeguards.
Your provider may determine telehealth is not appropriate for your situation at any point, and may recommend in-person care or refer you to another provider or a higher level of care.
State licensure limits where care can be provided. Your provider can only treat you via telehealth while you are physically located in a state where she is licensed/authorized to practice. You agree to inform us if your location changes.
Telehealth is not appropriate for emergencies. If you are experiencing a medical or psychiatric emergency — including thoughts of harming yourself or others — call 911 or go to the nearest emergency room immediately. You may also call or text 988 (Suicide & Crisis Lifeline), available 24/7.
Prescriptions via Telehealth
If clinically appropriate, your provider may prescribe medication based on your telehealth consultation. Certain medications, particularly controlled substances, are subject to additional federal and state regulations that may limit prescribing via telehealth alone, and may require an in-person evaluation in some circumstances.
Confidentiality
Information shared during your telehealth consultation is protected under the same confidentiality standards as an in-person visit, in accordance with HIPAA and Texas law, as described in our Privacy Policy.
Your Right to Withdraw Consent
You may withdraw your consent to telehealth services at any time, without affecting your right to future care. Withdrawing consent may mean transitioning to in-person care or a referral to another provider.
Your Responsibilities
You agree to:
Ensure you are in a private location for your consultation
Provide accurate information about your location, symptoms, and history
Confirm your identity if requested at the start of a session
Acknowledgment and Consent
By signing below (or checking the consent box at booking), I acknowledge that:
I have read and understand this Consent to Telehealth Services form
I have had the opportunity to ask questions, and any questions have been answered to my satisfaction
I voluntarily consent to receive mental health services from Celimot via telehealth
I understand the benefits, risks, and limitations described above