I give consent to MyCocun’s licensed independent contracted counselors to perform therapeutic
services determined to be necessary or advisable for the benefit of my health.
I understand that online counseling services include, but are not limited to, consultation and treatment
using interactive audio, video, and/or data communications. I understand that online counseling
services involve the communication of my medical/mental health information to the above referenced
provider. 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 benefits to which I would otherwise
I understand that the laws that protect the confidentiality of my medical information also apply to
online counseling services. As such, I understand that the information disclosed by me during the
course of my therapy is generally confidential. However, there are both mandatory and permissive
exceptions to confidentiality, including, but not limited to reporting abuse; expressed threats of violence
towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal
proceeding. I understand that the dissemination of any information is under the same HIPAA standards
as traditional therapy. Although rare, I understand that there are risks to Internet based services
including, not limited to, the possibility, despite reasonable efforts on the part of the Platform and/or
Therapist, that: the transmission of my medical information could be disrupted or distorted by technical
failures; the transmission of my medical information could be interrupted by unauthorized persons;
and/or the electronic storage of my medical information could be accessed by unauthorized persons.
I agree that the location of the therapy is the state where my licensed therapist is located, even when I
am communicating with my therapist by digital or text message platforms. I agree that my therapy is
under the licensing rules and laws of the state my therapist is licensed in.
By participating in on-line therapy services I am aware of potential benefits and risks. Some benefits
may include improved access to services, being able to choose the therapist I want with specialty
experience, the convenience of not having to travel to a therapist and using whatever means of
communication I am comfortable with.
Although risks are rare, I am aware there are possible risks which include that the information I am able
to give may not be sufficient to allow for a diagnosis-based treatment approach, that there may be a
delay in response from my therapist due to technical failures or unforeseen events, and that I may not
be able to respond to my therapist due to my own technology failures or unforeseen events.
I understand that my therapist may not be able to provide certain services to me. If my therapist
believes I need additional or other services, they may refer me to another specialist or type of care, such
as seeing a medical doctor for further evaluation and treatment.
If I want a “real time” or instant message style discussion with my therapist, I will need to schedule it.
Otherwise, my therapist and I will communicate asynchronously, not as instant message or in real time.
It is not recommended that I suddenly stop contacting my therapist or “drop out” without talking about
the termination of therapy. Therapists and clients talk about the expected length of therapy and ending
the therapeutic relationship.
Informed consent continues throughout the course of therapy and my therapist will continue to talk
with me about risks, benefits or educate me on the process of therapy as we go along.