to engage in teletherapy/coaching with PSLS. I understand that "teletherapy" includes consultation, treatment, transfer of medical data, emails, telephone conversations and education using interactive audio, video, or data communications. I understand that teletherapy/coaching also involves the communication of medical information, both orally and visually.

I understand that I have the following rights with respect to teletherapy:

• I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.
• The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy or consultation is confidential.
• I understand that there are risks and consequences from teletherapy, including, but not limited to, the possibility, despite reasonable efforts on the part of PSLS, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
• In addition, I understand that teletherapy based services and care may not be as complete as face-to-face services.
• I understand that I may benefit from teletherapy, but that results cannot be guaranteed or assured.
• I understand that I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my teletherapy sessions, (2) the information security on my computer, and (3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session.
• I understand that while email may be used to communicate with PSLS, confidentiality of emails cannot be guaranteed.
• I understand that I have a right to access my medical information and copies of medical records in accordance with HIPAA privacy rules and applicable state law.

I have read, understand and agree to the information provided above.