Informed Consent for Telehealth Supervision

Associate & Session Information

Understanding of Telehealth Supervision

Please review each statement and check to confirm your understanding.

I understand that telehealth supervision involves the use of video or audio technology to conduct supervision sessions remotely, in place of or in addition to in-person meetings. I understand the potential benefits of telehealth supervision, including greater flexibility and continuity of supervision when in-person meetings are not possible. I understand the potential risks of telehealth supervision, including technology failures, interruptions in connectivity, and the reduced ability to observe nonverbal cues compared to in-person supervision. I understand that reasonable steps will be taken to protect the privacy and confidentiality of information discussed during telehealth supervision, but that no electronic transmission can be guaranteed 100% secure. I understand that in the event of a technology failure during a scheduled session, my Supervisor and I will reconnect by phone or reschedule as needed. I understand that emergency situations are addressed per the Emergency Consultation Guidelines in the Supervision Handbook, and that telehealth supervision does not change those procedures.

Consent

I have read and understand the above, and I voluntarily consent to receive clinical supervision via telehealth from Christi Kersten, MA, LPC-S.