Informed Consent Click here to download our Informed Consent Policy (updated February 2026). "*" indicates required fields EmailThis field is for validation purposes and should be left unchanged.Patient Name*Facility*Consent checkbox* I consent to receive behavioral health services from Encounter Telehealth, which may include Medication Management (MM), Talk Therapy (TT), and/or Chronic Disease Management (CDM), as clinically appropriate. What services are you specifically interested in? Mark all that apply:* Medication Management (MM) Talk Therapy (TT) Chronic Disease Management (CDM) Patient/Patient's legal representative, please initial each of the following:* I have read the TELEHEALTH INFORMED CONSENT DOCUMENT carefully and my questions have been answered to my satisfaction. I certify that I have read, understand and agree to the PATIENT FINANCIAL RESPONSIBILITY AND BILLING AGREEMENT. The undersigned is the Patient or is duly authorized by or on behalf of the Patient to read and sign this agreement. I received a copy of Encounter Telehealth’s NOTICE OF PRIVACY PRACTICES, updated effective February 16, 2026, including the 42 CFR Part 2 provisions for SUD records. 42 CFR Part 2 — SUD Records Consent (see full notice on Page 2): I have read the Substance Use Disorder Records Notice on Page 2. I authorize Encounter Telehealth to use and disclose my SUD-related records for treatment, payment, and healthcare operations as described therein. I understand I may revoke this consent in writing at any time. Session Recording Consent (see full notice on Page 2): I have read the Session Recording Notice on Page 2. I understand that my telehealth sessions may be recorded for documentation, quality assurance, and insurance compliance purposes, and I consent to such recording as described. I understand I may withdraw this consent at any time. Artificial Intelligence (AI) Consent (see full notice on Page 2): I have read the AI Notice on Page 2. I understand that Encounter Telehealth may use AI-assisted tools to support clinical documentation, care coordination, and administrative functions, and I consent to such use as described. I understand I may ask questions or decline specific AI uses at any time. I requested and received a copy of the Telehealth Informed Consent Document, the Patient Financial Responsibility and Billing Agreement, and the Notice of Privacy Practice.Patient or Legal Representative*Patient or Legal RepresentativePATIENTLEGAL REPRESENTATIVEPrinted Name:*Relationship to Patient*Phone Number*** Signature:*Instructions: Click and hold left mouse or touchpad to sign.Date* Witness Securing Consent:Printed Name:*Relationship to Patient*Phone Number*** Signature*Instructions: Click and hold left mouse or touchpad to sign.Date* Δ
