Telehealth for behavioral health care

The purpose of consent forms is to document that a discussion took place and that the patient was informed and able to understand the information provided. Informed consent can be documented in writing or electronically before the appointment. It can also be recorded through verbal consent at the beginning of each session.

If someone else is joining the visit, such as a caregiver or another provider, the additional participant must also provide consent.

There are several basic steps you should follow to record informed consent:

• Reassure the patient that the information shared during the call is private.
• Discuss with children and adolescents that they can share confidential information and that you will not share it with their parents or guardians.
• Outline the rare circumstances when information may be shared with a caregiver, associate, or other entity.
• Explain to the patient what information you do and do not have access to, for example, the electronic medical record or state prescription drug monitoring program (PDMP).
• If the patient may have a history of substance use disorder, explain that this information will not be included in their medical record without additional consent.
• Discuss the importance of finding a private and quiet place for the appointment. Let patients know that they can use headphones if they need to ensure privacy.
• Confirm that other members of the household respect the patient’s need for privacy.

If you are a provider associated with a practice, unit, or facility that screens, diagnoses, or treats substance use disorder, you will need additional patient consent before you share information with other providers.

Tip: Make sure to have your medical and intake forms reviewed by your legal team.