1. I have the right to withdraw my consent at any time without affecting my right to future care or treatment, nor endangering the loss or withdrawal of any program benefits to which I would otherwise be eligible.

2. I understand that there are risks and consequences associated with telehealth including but not limited to, the possibility, despite reasonable efforts on the part of Upper Left Coast Counseling that: the transmission of my personal information could be disrupted or distorted by technical failures and/or the transmission of my personal information could be interrupted by unauthorized persons.

3. I understand that I may benefit from telemedicine but that results cannot be guaranteed or assured. In addition, I understand that if my therapist believes I would be bettered served by other interventions I may be referred to another behavioral health provider who can better meet my needs. I also understand that there are potential risks and benefits associated with any form of behavioral health treatment, and that despite my efforts and efforts of my provider, my condition may not improve, or may have the potential to get worse.

4. I understand that Upper Left Coast Counseling may not provide telemedicine services to me if I am outside of the State of Washington, and I understand that I may access telemedicine services from Upper Left Coast Counseling from within the State of Washington only.

5. I understand that I have a right to access my behavioral health information and copies of medical records in accordance with Washington state law.

By signing this document, I agree that certain situations including emergencies and crises are inappropriate for telehealth services. If I am in crisis or in an emergency, I should immediately call 911, go to the nearest hospital or contact Crisis Connections 211

I understand that an emergency situation may include thoughts about hurting or harming myself or others, having uncontrolled psychotic symptoms, or if I am in a life threatening or emergency situation. I have read and understand the information provided above. I have discussed telehealth with my Upper Left Coast provider, and all of my questions have been answered to my satisfaction. My signature below indicates my informed and willful consent to treatment using this platform.

I understand that you are doing the best you can with the tools you have and if you choose to work with me I offer genuine connection, professional strategies to access healthy coping, different perspectives and a safe place to explore new opportunities of personal growth.