This document needs to be signed in conjunction with the Informed Adult/Adolescent Consent Document.

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

    Jenine Smith Inc. Online Psychotherapy services are not for minors.

    Identify Verification:

    • All new clients will have to verify their age and identity by providing a scanned image of their identity document or other verifiable governmental identification.


    • Jenine Smith Inc online therapists will use Zoom video conferencing.

    • The client is responsible for securing his or her own computer hardware, internet access points, and password security.

    • Jenine Smith Inc. is not liable for confidentiality breaches when they are caused by client error.

    • Jenine Smith Inc. is not responsible for their client’s equipment failure, e.g. camera, and/or Internet service.

    • Jenine Smith Inc. is not responsible for lapses in confidentiality that are in direct response to the client’s actions.

    Disconnection Problems:

    • If video services are not available due to an unplanned equipment or service malfunction, sessions will occur via telephone.

    Recordings Are Prohibited:

    • Clients are not allowed to make an audio or video recording of any portion of the session.

    Risk of Harm:

    • Online therapy is not a crisis based clinical service.

    • Online psychotherapy may not be appropriate for clients with active suicidal or homicidal thoughts, or clients who are experiencing acute mental health problems, such as manic or psychotic symptoms.

    • It is the responsibility of the client to inform their clinical psycholgist if they are at risk of harm to self or others.

    • At intake, a client who reports being at risk of harm to self or others, will not be offered online psychotherapy services.

    • If through the intake evaluation or subsequent psychotherapy sessions, a client is deemed to be at risk of harm to self or to others, the clinical psychologist will terminate the sessions, while providing alternative referral suggestions.

    • If a client who was not formerly at risk, should become at risk of such harm to self or others, they must immediately report it to their treating clinical psychologist. In such cases, a client may be referred to a Psychiatric clinic where they will receive personalized face to face treatment.

    Confidentiality Restrictions:

    • The laws that protect the confidentiality of any medical information also apply to online psychotherapy.

    • Information about the client will only be released with his or her express written permission, with the exceptions of the following cases

      • If the counselor determines risk of self-harm

      • If the counselor determines risk of harm to others

      • If the counselor is informed about or suspects abuse, neglect, or exploitation of a minor or of an incapacitated adult

      • If the counselor believes that someone’s mental condition leaves the person gravely disabled


    • The Clinical psycholgist will maintain records of online psychotherapy and/or consultation services.

    • All clinical records will be maintained as required by applicable legal and ethical standards according to HPCSA.

    No Shows or Late Cancellations:

    • I furthermore understand that if my appointment is not cancelled 36 hours in advance, I will be held liable for the full consultation fee.

    • Client signature

    I understand the risks and limitations to online psychotherapy. By signing this consent, I agree to abide by its

    You can draw your signature with your mouse or track pad