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Disclosure of Policies for Telemental Health Services 

The following information is provided to clients who are seeking Telemental health therapy or counseling. This document covers your rights, risks, and benefits associated with receiving services, my policies, and your authorization. Please read this document carefully and in its entirety and note any questions you would like to ask or have clarified before signing this document.

Client’s Rights

  • I understand I have the right to decide to end the use of Telemental health options at any time without prejudice.
  • I understand I have the right to ask any questions about Telemental health procedures utilized during therapy.
  • I understand that I may benefit from Telemental health services but that results cannot be guaranteed or assured.
  • I understand that Kitsap Counseling & Hypnotherapy Center* may not provide Telemental health services to me if I am outside of the State of Washington, and I understand that I may access Telemental services from Kitsap Counseling & Hypnotherapy Center* from within the State of Washington only.
  • I understand that I have a right to access my mental health information and copies of medical records from a Telemental health sessions just as I do in-person sessions.

Benefits and Risks

Telemental health refers to psychotherapy services that occur via phone, email, or synchronous video conferencing. All of our interactions will fall under this term.

  • I understand that there are risks and consequences associated with telemedicine including, but not limited to the possibility, despite reasonable efforts on the part of my therapist, that the transmission of my personal health information could be disrupted or distorted by technical failures.
  • I understand that Telemental health-based services and care may not be as complete as face-to-face services.
  • I understand if my therapist believes I would be better served by another form of psychotherapeutic service (e.g. face-to-face services) I will be referred as necessary to those who can provide such services in my geographic area.

In addition to the identified risks, there are several benefits that come from using technology. For instance, it allows therapist to connect with people who may otherwise not be able to access services; there is an opportunity for more flexibility in scheduling; and convenience in being able to connect from a space of your choosing.

Best Practices

In order to protect your confidentiality and to facilitate the security of your information as much possible, here is a list of recommendations:

  • Always engage in sessions in a private location where you cannot be overheard by others.
  • Use a private phone, or device.
  • Do NOT record any sessions without prior permission from your therapist.
  • Password protect any technology you will be interacting with your therapist on.
  • Always log out or hang up once sessions are completed.


The laws that protect the confidentiality of my medical information also apply to Telemental health services. As such I understand the following:

  • I understand there are mandatory exceptions to confidentiality including, but not limited to: reporting child, elder, and dependent adult abuse and/or neglect.
  • I understand there is an exception to confidentiality if I express or make credible threats of violence towards a identified person (Tarasoff’s Law) or an unidentified person or group of persons (Volk Decision).
  • I understand there is an exception to confidentiality if I express or am observed to be a danger to myself.
  • Where I make my mental or emotional state an issue in a legal proceeding.

I understand that Kitsap Counseling & Hypnotherapy Center’s* platform(s) conform to Federal and State HIPAA compliance standards to reasonably protect my privacy and confidentiality.

Payment for Services

Payments for services are only accepted via credit or debit card and utilizes SQUARE for phone sessions per the Kitsap Counseling & Hypnotherapy Center’s Disclosure Agreement and Acknowledgement of Privacy Practices. Session rates are the same as in-person visits.

Disruption of Service

In the event of technology disruption or failure, it is important to have a plan on how to reconnect to the Telemental health session, generally the therapist will attempt to contact you via phone in the event of a video conference failure and email in the event of a phone failure or disruption. Generally, in the case of a technology failure sessions are billed in fifteen-minute increments (if a session fails at 15 minutes you would be charged ¼ of the session fee; if session fails between 16 minutes and 30 minutes you would be charged ½ of the session fee, etc.).

Emergency Management Plan

Kitsap Counseling & Hypnotherapy Center* does not provide emergency services. In the event of an emergency, it is imperative you are aware of local resources in your area. As a precaution, I will ask for your physical location (address) and an alternate way to reach you, as well as an emergency point of contact. These must be in place prior to continuing the session and will be asked for on your Informed Consent Agreement.

Version 4.0 / Dated April 18, 2023