98-084 Kamehameha Highway Suite 301-B Aiea, HI 96701
Phone: (808) 486-4900 * Fax: (808) 486-4901

In light of recent health concerns regarding COVID-19, it may be necessary to stop meeting in person for individual therapy sessions and to continue these and related services via telehealth. Telehealth involves the practice of mental health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data using interactive and electronic audio and video communications.

Before you agree to participating in telehealth, please carefully review the possible risks and benefits of electronic communication:

    1. There is a risk of the electronic connection being disrupted due to technical difficulties. Thus, prior to the start of your telehealth session, your therapist will arrange a process of re-establishing a connection.
    2. Although your therapist uses a HIPAA-compliant video platform, your confidential information may be accessed in spite of your therapist’s best effort to maintain a secure connection.
    3. Meeting via electronic video is not the same as meeting in-person as technology can alter the image and sound quality.
    4. The benefit of telehealth includes the ability to access mental health services when in-person meetings are not available.
By signing this form, you are consenting to participate in the use of telehealth services for mental health treatment. Consenting to telehealth involves the following (“I” refers to the patient):

1. I can choose to stop and/or withdraw my consent to telehealth at any time without affecting my right to future care.
2. I agree to contact 911 in case of an emergency.
3. I agree that confidentiality may be breached should I become suicidal, homicidal, or raise the suspicion of child or elder abuse.
4. I agree to disclose my physical location, an alternate contact number, and an emergency contact to my therapist at the start of the telehealth session.
5. I agree that I will not record the telehealth session.
6. I agree to finding a private and quiet space in which to participate in the telehealth session. 7. I agree that only the participants involved in the telehealth session can and will be present in the room.
8. I agree that Dr. Mavis M. Alaimalo can choose to stop telehealth sessions should she determine it is in my best interest or for my safety. Dr. Alaimalo will work to find alternate means of receiving services should this be the case to include a referral to another mental health Provider.
9. I agree to have my parent or legal guardian consent to my participation in telehealth sessions if I am under the age of 18 years.

By signing this form, I consent to participation in telehealth services and have reviewed the risks and benefits of telehealth participation.