Consent For Teletherapy



I understand that there may be times when it is clinically appropriate to have sessions via teletherapy. I hereby consent to engage in teletherapy with Karen M.Buckley. 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 also involves the communication of my medical/mental health information, both orally and visually.

  • Please contact your insurer prior to the session to confirm coverage. You are responsible to contact your insurance company to confirm coverage prior to the session.
  • Please contact me at least 48 HOURS in advance of your scheduled appointment to inform me that you wish to participate in a video session.
  • If insurance does not cover a teletherapy session, ​you will be responsible for the cost of the session.

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

  1. I have the right to withhold or withdraw consent at any time without affecting my right to future treatment.
  2. The laws and professional standards that apply to in-person behavioral services also apply to telehealth services. This document does not replace other agreements, contracts, or documentation of informed consent.
  3. I understand that there are risks and consequences from teletherapy, including, but not limited to, the possibility, despite reasonable efforts on the part of Karen M. Buckley, 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.
  4. In addition, I understand that teletherapy-based services and care may not be as complete as face-to-face services. I also understand that there are potential risks and benefits associated with any form of psychotherapy.
  5. I accept that teletherapy does not provide emergency services. If I am experiencing an emergency situation, having suicidal thoughts or making plans to harm myself, I understand that I can call 911 or proceed to the nearest hospital emergency room for help.
    I can call the Crisis Line in my area or the National Suicide Prevention Lifeline at 1.800.273.TALK
    (8255) for free 24-hour hotline support.
  6. 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.
  • To use the service, you must either have access to a smart phone or a computer with internet service and Chrome or Firefox browser. You can either download the Doxy app, or go to URL ​​llc -- This is a free, HIPAA compliant, video conferencing site. You will check into a virtual “waiting room” a few minutes prior to your scheduled session. You will clearly see my name listed in the waiting room as karenmbuckleyllc.
  • In order to participate in a video session, you must be in Washington State at the time of session.
  • Only you can participate in video sessions. No one else can be in the room with you and it
    must be an area where you cannot be overheard.


I have read, understand and agreed with the information provided above.

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Karen M. Buckley, LLC
2608 Pacific Ave SE Suite C, Olympia, WA 98501
Phone: (360) 556-0201
Fax: (360) 357-6218
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