TELEHEALTH FORM Please complete the SECURE on-line form below. Please enable JavaScript in your browser to complete this form.1. I hereby authorize Tift Area Psychiatric and Counseling Services to use the telehealth practice platform for telecommunication for evaluating, testing and diagnosing my medical condition. 2. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended. 3. I accept that the professionals can contact interactive sessions with video call. 4. I understand that my current insurance may not cover the additional fees of the telehealth practices and I may be responsible for any fee that my insurance company does not cover. 5. I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private. 6. I understand that HIPAA compliance and privacy for clients are being maintained but I cannot be guaranteed privacy on my end by Tift Area Psychiatric and Counseling. I am responsible for maintaining privacy of the appointment and session on my end. 7. Clients scheduled are expected to click the link sent to them no more than 5 minutes and no later than 15 minutes ensuring the session starts on time. NameFirstLastDateDateSignatureClear SignatureSubmit