Telehealth Informed Consent

Services Provided

Telehealth services offered by Grand Rapids Counseling Services and Grand Rapids Counseling Services’ engaged providers (our “providers”) will include the practice of psychological health care delivery, consultation, diagnosis, treatment, referral to resources, education and recommendation (the “Service”).

The Services provided may also include chart review, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following: (1) a review of health records, and/or test results via asynchronous communications; (2) live two-way interactive audio and video; (3) interactive audio with store and forward; or (4) output data from medical devices and sound and video files. The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Your provider typically provides telehealth services using one of the following tools: Google or Zoom.

Expected Benefits

Possible Risks

If you need to receive follow-up care, please contact your Grand Rapids Counseling Services provider. In the event of an inability to communicate as a result of a technological or equipment failure, please contact Grand Rapids Counseling Services at 616-988-3433 and

Service Limitations

By checking the box associated with “Informed Consent”, you acknowledge that you understand and agree with the following:

Patient Consent

I have read this document carefully, and understand the risks and benefits of the telehealth session and have had my questions regarding the session explained and I hereby give my informed consent to participate in a telehealth session under the terms described herein.