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Dr. Kat Derrig-Palumbo, LMFT
(626) 555-0142
Pasadena, CA
Informed Consent for Telehealth Psychotherapy
This document describes teletherapy services provided by Dr. Kat Derrig-Palumbo, LMFT ("your therapist") via the MyTherapyMatch secure platform. Your therapist — not the platform — is your treatment provider.
1. Nature of telehealth
Sessions are held by encrypted video, audio, and/or secure messaging. Telehealth has benefits (access, convenience) and risks (technology interruption, rare security risks despite encryption). If a session is interrupted, your therapist will call you at the backup number below.
2. Your location, each session
Because emergency services are dispatched by physical address and because licensure is tied to where you are located, you agree to confirm your physical address at the start of every session and to notify your therapist if you are in a different state.
3. Emergencies
Telehealth is not appropriate for all emergencies. In a crisis, call 911 or 988 (Suicide & Crisis Lifeline). Your therapist will maintain your local emergency contact and nearest hospital on file.
4. Privacy & recordkeeping
Sessions are protected under HIPAA and applicable state law. The platform operates under a signed Business Associate Agreement with your therapist. Sessions are not recorded without separate written consent. Confidentiality has legal limits (danger to self/others, abuse reporting, court orders), which your therapist will review with you.
5. Fees & cancellation
Sessions are $180 per 50-minute session. Cancellations require 24 hours' notice.
Agreement
Client name:
Client signature: Date:
Backup phone in case of disconnection:
Send for signature (demo)
PHQ-9
Score history — Jordan R.
Why location matters on every session
Dialing 911 reaches the dispatch center near the caller. If your client is in crisis 300 miles away, your 911 call may not help them. MyTherapyMatch verifies the client's physical address at the start of each session, so in an emergency you can call their local dispatch or send responders to a confirmed address.
It also protects your license: you must be authorized to practice where the client is located at session time. If a client silently attends from another state, you may be practicing without a license there. We surface the client's state every session.
Emergency workflow
Listing details
Credential verification
Our promise to you (the honest version)
We will not promise you clients. Most therapy clients still come from referrals, and anyone who guarantees you a full caseload is selling something. What we do promise:
Email system
Email templates
{{name}} becomes their first name(s) automatically. Changes apply to all future emails the moment you save.Therapists
Audit log (latest 200)
1 · The free pass ended in 2023
During COVID, federal regulators (HHS OCR) announced they would not penalize providers for using everyday video apps. That enforcement discretion expired August 9, 2023. Since then, using video tools without HIPAA safeguards and a signed Business Associate Agreement is once again an enforceable violation.
2 · A BAA isn't automatic — even if you pay
Zoom offers a BAA only on paid plans — and even then it isn't automatic: you must affirmatively opt in and accept it in your account settings. Zoom's own documentation states customers "are responsible for ensuring their use of Zoom's services aligns with their obligations under HIPAA." Free Zoom, FaceTime, and consumer video apps offer no BAA at all. The compliance gap lands on you, the licensee — not the software company.
3 · General-purpose tools, clinical-grade risks
In 2020 Zoom settled FTC charges that it falsely advertised "end-to-end, 256-bit encryption" while keeping keys that could access meeting content, and left some cloud recordings unencrypted on its servers for up to 60 days. A general-purpose tool also does nothing therapy needs: no consent workflow, no client location for emergencies, no intake, no clinical notes, no license linkage.
4 · What a therapy session actually requires
Professional telehealth guidelines expect you to verify the client's identity and location, hold telehealth-specific informed consent, plan for emergencies near the client, and document it all. MyTherapyMatch makes each of those a built-in step — the platform is the compliance checklist.
And why not a BetterHelp-style platform?
Platforms that employ or pay therapists per session take a large cut of the fee and own the client relationship. In 2023 the FTC ordered BetterHelp to pay $7.8 million in consumer refunds over charges that it shared clients' email addresses, IPs, and health-questionnaire answers with Facebook, Snapchat, Criteo, and Pinterest for advertising — and banned it from doing so again. Many therapists also report pay rates far below their private-practice fee.
MyTherapyMatch is structurally different: you are never our employee, we never touch your session fee, and your client data is never an advertising asset. Flat fee for the office + directory. That's the whole business model.