Lyon Counseling Telehealth Consent Form

Step 1:

Please view and/or download (for your records) the Lyon Counseling Telehealth Consent Form.

Step 2:

Carefully read the following section:

Telemental Health Informed Consent


I understand and agree to receive telemental health services from my therapist. This means that my therapist and I will, through a live interactive video connection, meet for scheduled psychotherapy sessions under the conditions outlined in this document and the Lyon Counseling LLC Therapy Agreement form.

I understand the potential risks of telemental health, which may include the following: 1) the video connection may not work, or it may stop working during a session; 2) the video or audio transmission may not be clear; and 3) I may be asked to go to my therapist’s office in person if it is determined that telemental health is not an appropriate method of treatment for me.

I recognize the benefits of telemental health, which may include the following: 1) reduced cost and time commitment for treatment due to the elimination of travel; 2) ability to receive services near my home or from my home; and 3) access to services that are not available in my geographic area.

I give my consent to engage in psychotherapy via videoconferencing. I understand that my therapist uses HIPAA-compliant technology to transmit and receive video and audio and stores all notes and information related to my treatment in a manner that is compliant with state and federal laws. I understand that it is my responsibility to ensure that my physical location during videoconferencing is free of other people to ensure my confidentiality. Furthermore, I understand that recording my sessions is prohibited.

I understand that I have the option to request in-person treatment at any time, and my therapist will assist in scheduling this or make a referral if travel to the therapist’s office is not feasible for me. I understand that closer providers may not be available depending on my location.


I understand the limitations to confidentiality with my therapist include reasonable belief that I am a danger to myself or others. I understand that, if my therapist reasonably believes that I plan to harm myself or someone else, my therapist will contact local emergency services to come to my location and ensure my safety.


Step 3:

Please provide the client's name.

Step 4:

Please provide the Legal Guardian's name (if applicable)

Step 5:

Please make sure you have read and understood all terms, conditions and agreements as laid out in the Lyon Counseling Telehealth Consent Form and acknowledge below:

I have read and accept the conditions as they are outlined and detailed.

Sign Here