Informed Consent -

Client Information Form -

I understand that the service provided through BetterHelp is not intended for crisis situations and urgent needs. While my therapist, Therapist Name, LPC (NY LPC #00000) is a licensed therapist in the state of State, Better Help services and/or online or text-based services may not be the best avenue for me to receive mental health care. If the use of this site or online services are not appropriate for my situation, I understand that my therapist will assist in providing me with additional options of in-person referrals where I can obtain care.

Verification of Identity and Location at the time of session:

I understand and agree that my therapist needs to verify my identity and may request to see a form of photo ID at the start of our work together. This is to verify my identity including legal name, date of birth and home address.

If my address on the submitted ID is not included or not current, I will provide my clinician with my current correct address.

I agree to provide my clinician with a phone number to reach me in an emergency. I agree to provide an emergency contact name and number as well.

I also agree to provide my therapist with my current location, vehicle make/model/color, and license plate number if I am meeting from inside of a car (some clients do this for privacy.) I understand that, for safety reasons, my therapist will NOT meet with clients in a moving vehicle, and that failure to provide this information at the start of my session will result in the session being cancelled.

In a crisis situation, I agree that I will either:

• Call 911 or go to the nearest emergency room for in-person help for an immediate crisis
• Call 988 for mental health related crises (Newly added)
• TEXT: You can text the Crisis Text line by texting “Help” to 741-741
• PHONE/VOICE: Call the Crisis Hotline via phone at (800) 273-8255
• You can also call your psychiatrist or prescriber for assistance

I understand that my confidentiality is fully protected by law with the exceptions of these FOUR circumstances:

• If my therapist has concerns or suspicions of abuse or neglect of a child, elderly person, someone with a disability, or someone otherwise unable to care for themselves