Ann E. Drouilhet, LICSW, LMFT
40 Speen St. Suite 106
Framingham, MA 01701
508-877-3660 x2
adrouilhet@gmail.com
CONSENT FOR TELEHEALTH PSYCHOTHERAPY
Ann Drouilhet, LICSW, has offered to provide psychotherapy via phone or telehealth consultation.
I authorize Ann Drouilhet, LICSW, to allow us to meet via smartphone or a secure HIPAA compliant
online video conference service platform.
She has explained to me how the video conferencing technology that will be used will not be the same
as a direct client/psychotherapist session due to the fact that we will not be in the same physical
space.
I understand that a telehealth consultation has potential benefits including easier access to care,
continuity of care, and the convenience of meeting from a location of my choosing.
I understand there are potential risks to this technology, including interruptions, unauthorized access,
and technical difficulties, which cannot be predicted. I understand that my health care provider or I
can discontinue the telehealth consult/session if it is felt that the videoconferencing connections are
not adequate for the situation.
I understand that the telemedicine session will not be audio or video recorded at any time, and that
we will both disable computer and device-generated recording to the best of our abilities.
I understand that it is important to connect from a quiet room where my privacy is guaranteed.
My consent to participate in this telemedicine service shall remain in effect until I revoke my consent
in writing.
I have had the opportunity to ask questions in regard to this procedure.
I confirm that I have read and fully understand the above.
