1.                   I understand that Melissa Berggren-Marshall, Ph.D. ("my provider") is a licensed psychologist and that she provides a variety of psychotherapy/testing/evaluation services through Inner Light Psychological Services, PLLC ("Inner Light").  Psychotherapy/testing/evaluation is the process by which personal mental health conditions and challenges are discussed, evaluated, and treated in a professional and structured setting, using evidence-based methods and techniques.

2.                   I understand that all psychotherapy/testing/evaluation services at Inner Light is voluntary and that my active participation and cooperation with my provider is a key factor in the outcome of my treatment.  I also understand that my provider at Inner Light cannot guarantee outcomes and that providing psychotherapy services is not an exact science.  I acknowledge that my provider has made no guarantee or assurance to me as to the effect, result, or outcome of any service, assessment, test, evaluation, technique, method, or treatment she may recommend. However, my provider will explain clearly stated reasons, goals, and objectives for continuing/discontinuing certain techniques, methods, and treatments.

3.                   I understand that being open and honest with my provider is an important part of receiving psychotherapy/testing/evaluation services, and also that doing so poses inherent risks including experiencing traditionally uncomfortable feelings (such as anxiety, shame, guilt, fear) or the recall of unpleasant events.  These risks are hopefully short-term, in service of obtaining hopefully long-term benefits (such as reduction in feelings of distress, resolutions to specific problems, development of healthy coping skills). My provider recognizes and appreciates that engaging in the process of psychotherapy/testing/evaluation services may be challenging at times for me and will do her best to help me handle the risks and experience at least some of the benefits.

4.                   I understand that my provider at Inner Light is required to give me clear descriptions regarding any identified challenges, diagnoses, personal strengths/limitations, and/or services, assessments, evaluations, techniques, methods, or treatments recommended to me, including associated risks, benefits, and alternatives.  I am aware that I can bring forward any questions or concerns I may have with my provider at any time and that I can discuss the risks, benefits, and alternatives of any recommended service, assessment, evaluation, technique, method, or treatment with my provider at any time.

5.                   Times, dates, and session length will be discussed with my provider at Inner Light.  I understand that my provider may make diagnostic and treatment recommendations with which I do not agree (e.g., modality of treatment, duration of treatment, frequency of visits, etc.).  While I will endeavor to work with my provider to find techniques, methods, and treatments that are beneficial to me, I understand that I have the right to refuse any particular treatment at any time.  I also understand that I have the right to end my treatment with Inner Light at any time.

6.                   I understand that in the case of an emergency, the National Suicide Prevention Hotlinemaintains a 24-hour "on call" system, which can be reached by calling 1-800-273-8255.  Calling 911 is always an option available to me as well.  An emergency is an urgent issue, that is generally life-threatening, which requires immediate action.

7.                   I understand that this Informed Consent to Treatment form is not intended to be "all inclusive" of aspects of my treatment.  It is only intended to provide some useful information before deciding to engage in treatment.

8.                   I understand that I may be required to sign additional consent forms associated with receiving psychotherapy/testing/evaluation services at Inner Light.

I have reviewed this Informed Consent to Treatment Form and have been given the opportunity to ask questions. A copy of this form is available upon request.  By signing this form, I indicate my understanding of the information discussed above and consent to treatment and testing.

I understand that Melissa Berggren-Marshall, PhD ("my provider") at Inner Light Psychological Services, PLLC, ("Inner Light") will be delivering my psychotherapy/counseling treatment from New Hampshire and that I will be receiving this treatment from another location in another state via telehealth.  My provider is a psychologist licensed under the laws of New Hampshire, Massachusetts, and Maine.

What is Telehealth/Telemedicine?
Telehealth/telemedicine ("telehealth") means the delivery of health care services, including psychotherapy/counseling services, such as diagnosis, consultation, or treatment, using electronic communications, information technology or other means over a secure connection that complies with applicable privacy requirements.  It is a way to receive psychotherapy/counseling treatment from my provider when she is located in one location and I am located in another.

Telehealth may include the use of live interactive audio and video communication, store and forward technology, email, audio-only telephone communication, electronic messaging, facsimile machines, other asynchronous transmission of health information so long as the communication technology(ies) used is/are secure and compliant with applicable privacy requirements.

Telehealth is meant to replicate traditional in-person treatment as much as reasonably possible.  Treatment recommendations made via telehealth are held to the same standards of appropriate practice as those in traditional provider-patient settings.

Expected Opportunities & Possible Limitations of Telehealth
Telehealth provides improved access to mental health care by enabling a patient to remain in his/her/their home or other location (or temporary home out-of-state) while the provider delivers services from another location.  Telehealth allows a patient to obtain the expertise of a distant specialist and can serve as a more efficient and more comfortable setting to deliver and receive psychotherapy/counseling.

I understand that the use of telehealth presents certain limitations and risks, including the following, which may occur in rare instances:

 -         Transmitted information may be distorted or insufficient to allow for appropriate mental health decision making;
 -         There may be unanticipated delays in diagnoses or treatments due to equipment or technology failures or deficiencies;
 -         Records of services provided may be lost through technical failures; and
 -         Security protocols could fail, causing a breach of privacy of personal health information.

Informed Consent to the Use of Telehealth
I understand that treatment with Inner Light will primarily be provided via live interactive audio and video communication and that my provider will discuss with me available alternatives and supplements to this treatment modality.  My provider will inform me of any other individuals who will be with her during my treatment.  While I will endeavor to work with my provider to find permissible modalities of communication that are beneficial to me, I understand that I have the right to terminate a telehealth session at any time, without affecting the right to future care or treatment. 

I also understand that my provider may terminate the telehealth appointment if she feels the service is inappropriate for me in my current condition and may direct me to an alternate care service (i.e., Emergency Department, Urgent Care, or Specialist), as appropriate and in my provider's sole discretion.  I acknowledge that my provider's responsibility to provide psychotherapy/counseling services will end upon termination of the telehealth session.

I understand that I have the right to revoke my consent to the use of telehealth during my treatment at any time.  I also understand that a revocation of my consent to the use of telehealth will impact my ability to continue to receive treatment from Inner Light.

Information that may be used for my treatment may include medical records, medical images, live two-way audio and video sessions, output data from medical devices and sound and video files.  I understand that part or all of the information used in my treatment may become part of my mental health record.

In the event of an adverse reaction to treatment or if there is a telehealth equipment failure, I understand that I may choose to re-initiate telehealth services per instructions provided by my provider.  I hereby release and hold harmless my provider and/or Inner Light from any loss of data or information due to technical failures.

I understand that it is important to receive my treatment via telehealth from secure resources and in a location(s) that maximizes my security and privacy, and I will endeavor to facilitate my treatment accordingly.

Acknowledgement
I affirm that I have read and fully understand this Telehealth/Telemedicine Informed Consent form and have been offered a copy of it.  I have been given the opportunity to ask questions and that all my questions have been answered to my satisfaction.  My signature below indicates that I voluntarily consent to the use of telehealth in my treatment with Inner Light, and that I authorize Melissa Berggren-Marshall, PhD, to use telehealth during my treatment.

I understand that Melissa Berggren-Marshall, PhD ("my provider") at Inner Light Psychological Services, PLLC, ("Inner Light") will be delivering my psychotherapy/counseling treatment from New Hampshire and that I will be receiving this treatment from another location in New Hampshire via telehealth.  My provider is a psychologist licensed under the laws of New Hampshire.

What is Telehealth/Telemedicine?
Telehealth/telemedicine ("telehealth") means the delivery of health care services, including psychotherapy/counseling services, such as diagnosis, consultation, or treatment, using electronic communications, information technology or other means over a secure connection that complies with applicable privacy requirements.  It is a way to receive psychotherapy/counseling treatment from my provider when she is located in one location and I am located in another.

Telehealth may include the use of live interactive audio and video communication, store and forward technology, email, audio-only telephone communication, electronic messaging, facsimile machines, other asynchronous transmission of health information so long as the communication technology(ies) used is/are secure and compliant with applicable privacy requirements.

Telehealth is meant to replicate traditional in-person treatment as much as reasonably possible.  Treatment recommendations made via telehealth are held to the same standards of appropriate practice as those in traditional provider-patient settings.

Expected Opportunities & Possible Limitations of Telehealth
Telehealth provides improved access to mental health care by enabling a patient to remain in his/her/their home or other location (or temporary home out-of-state) while the provider delivers services from another location.  Telehealth allows a patient to obtain the expertise of a distant specialist and can serve as a more efficient and more comfortable setting to deliver and receive psychotherapy/counseling.

I understand that the use of telehealth presents certain limitations and risks, including the following, which may occur in rare instances:

 -         Transmitted information may be distorted or insufficient to allow for appropriate mental health decision making;
 -         There may be unanticipated delays in diagnoses or treatments due to equipment or technology failures or deficiencies;
 -         Records of services provided may be lost through technical failures; and
 -         Security protocols could fail, causing a breach of privacy of personal health information.

Informed Consent to the Use of Telehealth
I understand that treatment with Inner Light will primarily be provided via live interactive audio and video communication and that my provider will discuss with me available alternatives and supplements to this treatment modality.  My provider will inform me of any other individuals who will be with her during my treatment.  While I will endeavor to work with my provider to find permissible modalities of communication that are beneficial to me, I understand that I have the right to terminate a telehealth session at any time, without affecting the right to future care or treatment. 

I also understand that my provider may terminate the telehealth appointment if she feels the service is inappropriate for me in my current condition and may direct me to an alternate care service (i.e., Emergency Department, Urgent Care, or Specialist), as appropriate and in my provider's sole discretion.  I acknowledge that my provider's responsibility to provide psychotherapy/counseling services will end upon termination of the telehealth session.

I understand that I have the right to revoke my consent to the use of telehealth during my treatment at any time.  I also understand that a revocation of my consent to the use of telehealth will impact my ability to continue to receive treatment from Inner Light.

Information that may be used for my treatment may include medical records, medical images, live two-way audio and video sessions, output data from medical devices and sound and video files.  I understand that part or all of the information used in my treatment may become part of my mental health record.

In the event of an adverse reaction to treatment or if there is a telehealth equipment failure, I understand that I may choose to re-initiate telehealth services per instructions provided by my provider.  I hereby release and hold harmless my provider and/or Inner Light from any loss of data or information due to technical failures.

I understand that it is important to receive my treatment via telehealth from secure resources and in a location(s) that maximizes my security and privacy, and I will endeavor to facilitate my treatment accordingly.

Acknowledgement
I affirm that I have read and fully understand this Telehealth/Telemedicine Informed Consent form and have been offered a copy of it.  I have been given the opportunity to ask questions and that all my questions have been answered to my satisfaction.  My signature below indicates that I voluntarily consent to the use of telehealth in my treatment with Inner Light, and that I authorize Melissa Berggren-Marshall, PhD, to use telehealth during my treatment.

N.H. Code Admin. R. Mhp 502.02

(a) The board shall provide each licensee with a client bill of rights to read as follows:
"This Mental Health Bill of Rights is provided by law to persons receiving mental health services in the State of New Hampshire. Its purpose is to protect the rights and enhance the well being of clients, by informing them of key aspects of the clinical relationship. As a client of a New Hampshire Mental Health Practitioner, you have, without asking, the right:

   (1) To be treated in a professional, respectful, competent, and ethical manner consistent with all applicable state laws and the following professional ethical standards:

      a. For independent clinical social workers; the National Association of Social Workers;
      b. For pastoral psychotherapists; the NH Association of Pastoral Psychotherapists;
      c. For clinical mental health counselors; the American Mental Health Counselors Association; and
      d. For marriage and family therapists; the American Association for Marriage and Family Therapists.

   (2) To receive full information about your treatment provider's knowledge, skills, experience and credentials.

   (3) To have the information you disclose to your mental health provider kept confidential within the limits of state and federal law. Communications between mental health providers and clients are typically confidential, unless the law requires their disclosure. Mental health providers will inform you of the legal exceptions to confidentiality, and should such an exception arise, will share only such information as required by law. Examples of such exceptions include but are not limited to:

      a. Abuse of a child;
      b. Abuse of an incapacitated adult;
      c. Health Information Portability and Accountability Act (HIPAA) regulation compliance;
      d. Certain rights you may have waived when contracting for third party financial coverage;
      e. Orders of the court; and
      f. Significant threats to self, others or property.

   (4) To a safe setting and to know that the services provided are effective and of a quality consistent with the standard of care within each profession and to know that sexual relations between a mental health provider and a client or former client are a violation of the law (RSA 330-A:36).

   (5) To obtain information, as allowed by law, pertaining to the mental health provider's assessment, assessment procedures and mental health diagnoses (RSA 330-A:2VI).

   (6) To participate meaningfully in the planning, implementation, and termination or referral of your treatment.

   (7) To document informed consent: to be informed of the risks and benefits of the proposed treatment, the risks and benefits of alternative treatments, and the risks and benefits of no treatment. When obtaining informed consent for treatment for which safety and effectiveness have not been established, therapists will inform their clients of this and of the voluntary nature of their participation. In addition, clients have the right to be informed of their rights and responsibilities, and of the mental health provider's practice policies regarding confidentiality, office hours, fees, missed appointments, billing policies, electronic communications, managed care issues, record management, and other relevant matters except as otherwise provided by law.

   (8) To obtain information regarding the provision(s) for emergency coverage.

   (9) To receive a copy of your mental health record within 30 days upon written request (except as otherwise provided by law), by paying a nominal fee designed to defray the administrative costs of reproducing the record.

   (10) To know that your mental health provider is licensed by the State of New Hampshire to provide mental health services.

      a. You have the right to obtain information about mental health practice in New Hampshire. You may contact the Board of Mental Health Practice for a list names, addresses, phone numbers and websites of state and national professional associations listed in Mhp 502.02(a)(1)a.
      b. You have the right to discuss questions or concerns about the mental health services you receive with your provider.
      c. You have the right to file a complaint with the Board of Mental Health Practice."

(b) A licensee shall post a copy of the above mental health bill of rights in a prominent location in the office of the mental health practitioner and provide a copy upon request.

(c) A licensee shall provide a copy of the mental health bill of rights to the client and/or agency if the assessment, consultation or intervention is provided outside the office.

(d) A licensee shall, when a client is under the age of 18, assure these rights are applied through, and to, the parent or guardian of their client, unless limited by a court order.

N.H. Code Admin. R. Mhp 502.02
(See Revision Note at chapter heading for Psy 100) #5675, eff 7-22-93; EXPIRED: 7-22-99
New. #7625, eff 1-10-02; ss by #8056, eff 2-28-04; ss by #9854, eff 1-25-11

Amended by Volume XXXV Number 10, Filed March 12, 2015, Proposed by #10790, Effective 2/24/2015, Expires2/24/2025.
Amended by Volume XLI Number 45, Filed November 10, 2021, Proposed by #13052, Effective 10/19/2021, Expires 10/19/2031