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This is an electronic copy of the UC Irvine Counseling Center Information and Consent for Services Form. The legal consent for services will be signed at the time of your scheduled first appointment. 

UCI Counseling Center

Virtual Services Information and Consent for Virtual Services

This document is an addendum to the UCI Counseling Center Information and Consent for Services form.  All aspects of information in that document apply to UCI Counseling Center virtual services.

In California, “Telehealth” (also known as virtual service) is defined as a method to deliver health care services using information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care while the patient/client and provider are at two different sites. This form of service usually consists of live videoconferencing through a personal computer with a camera but may also be conducted by other means of audio and/or visual real time communication.

Virtual services should not be viewed as a substitute for face-to-face therapy appointments; it is an alternative form of therapy with certain limitations. As such it is not appropriate for all clients. For example, in-person or a combination of in-person and virtual services may be preferred when a client has high risk for harming themselves or others or is experiencing acute psychosis (e.g., their perception of reality is affected by delusions or hallucinations). When developing your treatment plan, your provider will evaluate whether virtual services are an appropriate option for you to consider.

You are not required to use virtual services even if virtual services are determined to be an appropriate option for you. We will try to honor requests for in-person services when possible, but accommodating this preference may result in a delay of services or a referral to an off-campus provider.

Regardless of your preference for virtual or in-person services, we ask that you read and complete this consent form in case virtual services become necessary at some point in your services.  For example, if you are not able to make it to the Center on a given day for your in-person session, you could call to have your appointment changed to a virtual appointment.  This consent for virtual services form would already be completed, avoiding delays.

Potential Benefits and Risks of Virtual Services

Virtual services have many benefits, including allowing flexibility when clients have difficulty making it to the center for an in-person appointment. Additionally, some clients prefer the virtual format due to increased comfort and/or the convenience that this format affords.

The risks of virtual services include the following:

• Some clients may feel less comfortable with virtual services than in-person services.
• Virtual services provide fewer visual and/or audio cues to the provider and client, leading to an increased potential for misunderstanding.
• Virtual services may have disruptions or delays due to internet service and quality of the technology used.
• Some virtual sessions may be conducted while the Counseling Center provider and/or the client are/is not physically present in the Counseling Center. While reasonable measures to ensure confidentiality will be taken, the standards may not be as high as those implemented in the Counseling Center offices (e.g., less soundproofing).
• There is potential for other people to overhear sessions if you are not in a private place during the session.

• In rare cases, security protocols could fail, and confidential information could be accessed by unauthorized persons.  

Your Responsibilities for Virtual Services 

You must make sure you are in California at the time of your appointment, as we are not able to provide services to clients who are located outside of the state. 

• You must inform your provider of your location during each virtual appointment.  

• You will wear the same attire that you would to an in-person session. 

• At each virtual appointment, you must give your provider the name and phone number of an emergency contact person who is available at the time of the appointment. Your provider will only contact this person, if your provider believes a serious threat to your safety exists. 

• The most reliable backup for a technology failure is a phone.  Therefore, it is recommended that you have a phone available for the entire duration of the appointment.  You will provide the best phone number for reaching you during each appointment. 

• You will not record any appointments. The Counseling Center will not record your sessions without specific written consent to do so.  

• You may need certain computer or cell phone systems to use virtual services. You are solely responsible for any cost associated with any necessary equipment, accessories, or software you purchase to take part in virtual services. 

Other Recommendations 

• It is recommended that you only engage in sessions from a private location where you will not be overheard or interrupted. If you cannot find a private location, please ask to schedule to use one of our Virtual Services (VS) rooms in the Counseling Center for your appointment(s). 

• It is recommended that you ensure that the computer or device you use for virtual services has updated operating and anti-virus software. 

Urgent Situations During and After Hours 

If you are experiencing a life-threatening emergency, call 911, call the UC Irvine Campus Police at (949) 824-5223, or go to the nearest emergency room. Please also use the same procedure for emergencies during a virtual session if all forms of technological connections fail.  For other urgent situations, please call or come to the Counseling Center or call (949) 824-6457 during our business hours to speak to your assigned therapist (or to the crisis care therapist if your assigned therapist is not available). For after-hours urgent needs, call our front desk at (949) 824-6457 and select option # 2 to speak immediately with a mental health professional.  

If you have questions or concerns about the information and conditions described above, please discuss them with your provider before signing this form.

 Version June 2024