TELEHEALTH INFORMED CONSENT (Electronic Attestation)
Effective Date: 7/20/2026
Birches Health primarily provides outpatient behavioral health services through telehealth rather than in-person visits.
Services may include counseling, therapy, substance use disorder treatment, behavioral health assessments, recovery support, care coordination, group services, referrals, and other related behavioral health services.
Services may be provided by licensed clinicians, counselors, and other qualified members of the Birches Health care team. Recovery support and non-clinical services may also be provided by peer support specialists acting within the scope of their role and training. Peer support specialists do not provide psychotherapy or other services that require professional licensure unless separately authorized by law and credential.
Nature of Treatment
Behavioral health treatment can help address concerns related to mental health, substance use, gambling, stress, relationships, and other personal challenges.
Treatment may include assessments, counseling, therapy, education, recovery support, treatment planning, referrals, and other services that are appropriate for your needs.
While treatment may be helpful, no specific results or outcomes can be guaranteed.
Benefits of Treatment
Possible benefits of treatment include:
Improved mental health and well-being;
Reduced symptoms;
Better coping skills;
Improved relationships and daily functioning; and
Progress toward personal recovery and wellness goals.
Risks of Treatment
Behavioral health treatment may involve risks, including:
Discussing difficult experiences, thoughts, feelings, or behaviors;
Feeling sad, anxious, upset, frustrated, or uncomfortable at times;
Increased awareness of personal challenges;
Temporary worsening of symptoms before improvement occurs; and
Changes in relationships, routines, or personal circumstances resulting from treatment decisions.
Alternatives to Treatment
Alternatives may include choosing not to receive treatment, seeking services from another provider, using community resources, participating in support groups, or pursuing other available treatment options.
Telehealth Services
Telehealth involves providing healthcare services through electronic communication technology when you and your provider are in different locations.
Telehealth services may include:
Live video visits;
Telephone visits, when appropriate and permitted by law;
Secure messaging or patient portal communications; and
Review of information you provide, such as questionnaires, screening tools, or health history forms.
Your provider will determine whether telehealth is appropriate for your needs.
Benefits of Telehealth
Possible benefits of telehealth include:
Improved access to care;
Greater convenience;
Better continuity of services; and
The ability to receive care when in-person services may not be reasonably available.
Risks and Limitations of Telehealth
You understand that telehealth has risks and limitations, including:
Technology failures, interruptions, or poor connection quality;
Reduced ability to assess certain conditions compared to in-person services;
Privacy risks if your device, internet connection, or physical environment is not secure; and
The possibility that telehealth may not be appropriate for all situations.
If telehealth is not clinically appropriate or technically feasible, your provider may recommend in-person services or referral to another provider.
Telehealth sessions are not routinely recorded by Birches Health. Any recording would require separate notice and authorization when required by applicable law.
Patient Location and Provider Licensure
You understand and agree that:
Telehealth services may only be provided while you are physically located in a state where your provider is licensed or otherwise authorized to practice;
You are responsible for accurately providing your current physical location at each visit;
If your location changes during a visit, you must notify your provider immediately;
Availability of services depends on provider licensure and legal authorization in the state where you are located; and
Birches Health may be unable to provide services if your provider is not authorized to practice in the state where you are located.
Privacy and Confidentiality
Your information is protected by applicable federal and state privacy laws, including HIPAA.
Birches Health takes reasonable steps to protect your information. However, no electronic system can be guaranteed to be completely secure.
Information shared during treatment is generally kept private. However, Birches Health may disclose information without your permission when required or permitted by law, including situations involving:
Suspected abuse, neglect, or exploitation;
Court orders or other legal requirements;
Medical emergencies;
Serious threats of harm to yourself or others; or
Other situations required or permitted by law.
Additional information is available in Birches Health's Notice of Privacy Practices.
Treatment Team and Care Coordination
Your care may involve more than one member of the Birches Health care team. As permitted by law, information may be shared among members of your treatment team and with other healthcare providers involved in your care when needed to support treatment, coordinate care, process payment, operate healthcare services, or as otherwise permitted by law.
Emergencies and Crisis Situations
Telehealth services are not appropriate for emergencies.
If you are experiencing a medical or mental health emergency, call 911 or go to the nearest emergency room.
You may be asked to provide your current location and emergency contact information before or during services. This information may be used to support safety planning and emergency response when necessary.
If your provider believes you are at immediate risk of harm to yourself or others, or if otherwise permitted or required by law, Birches Health may contact emergency services, emergency contacts, or other appropriate resources based on your disclosed location.
Birches Health (Non-Emergency Contact): (833) 483-3838
Hours: Monday–Friday, 9:00 a.m. – 5:00 p.m. (excluding federal holidays)
Your Choice
Participation in treatment is voluntary.
You may ask questions about treatment or telehealth services at any time.
You may refuse treatment, refuse telehealth services, or withdraw your consent at any time. Withdrawal of consent will not affect your right to seek future care, although alternative care options may be limited based on provider availability, licensure requirements, location, or clinical considerations.
Questions, Concerns, or Complaints
You may contact Birches Health at any time with questions, concerns, or complaints regarding your care or services.
Birches Health
hello@bircheshealth.com
(833) 483-3838
Electronic Attestation
By selecting "I Agree" or otherwise electronically acknowledging this document, you confirm that:
You have read and understand this Behavioral Health Treatment and Telehealth Informed Consent;
You have had the opportunity to ask questions and understand that you may ask questions at any time;
You understand the nature of the services offered by Birches Health;
You understand the benefits, risks, and alternatives to treatment;
You understand the benefits, risks, and limitations of telehealth services;
You understand the requirements regarding your physical location and provider licensure;
You understand the limits of confidentiality;
You understand that telehealth is not appropriate for emergencies;
You understand that participation in services is voluntary; and
You voluntarily consent to receive behavioral health services through telehealth from Birches Health.
Your electronic consent will be documented and maintained as part of your medical record in accordance with applicable federal and state laws.