Consent for Virtual Music Therapy Services

Please complete the following form in order to provide consent for teletherapy services with Music Therapy Connections.

Client's Name:*
First Last
Program Director's Name (if applicable):
First Last
City of Residence*
School or Program Name (if applicable):
Authorization and Consent

The purpose of this form is to obtain your consent to participate in virtual music therapy sessions with Music Therapy Connections, LLC.

1. Purpose and Benefits

The purpose of this consent is to establish and maintain access to music therapy services when in-person contact is restricted or not available.

2. Nature of Virtual Music Therapy Services

a) Details of you and/or your child’s medical history, music therapy assessment, or other sensitive content may be discussed through the use of interactive video, audio, and telecommunication technology.

b) I understand that video, audio, and/or digital photo may be recorded during the virtual music therapist sessions to be used by the client between sessions or for music therapy and supervision purposes.

c) Just as in typical treatment, while there may be potential benefits to engaging in virtual sessions, benefits cannot be guaranteed.

3. Medical Information and Records

All existing laws regarding your access to medical information and copies of your medical records apply to virtual music therapy services. Additionally, dissemination in any patient-identifiable images or information from the virtual music therapy session shall not occur without your consent, unless authorized under existing confidentiality laws.

4. Confidentiality

Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with virtual music therapy sessions. All existing confidentiality protections under federal and Illinois law apply to information disclosed in virtual music therapy services.

5. Risks and Consequences

I understand virtual music therapy sessions will be similar to typical sessions, except interactive video technology will allow you to communicate with the music therapist at a distance. I also understand that there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my music therapist or I can discontinue or reschedule the virtual music therapy session if it is felt that the video conferencing connections are not adequate for the situation. The use of video technology to deliver music therapy services is a new technology and may not be equivalent to direct client to professional contact. Delays in services could occur due to deficiencies or failures of the equipment. In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.

6. Rights

You may withhold or withdraw consent to virtual music therapy services at any time without affecting your right of future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. If the client chooses not to participate in virtual sessions while COVID-19 restrictions are in place, services will have to be suspended until the situation changes and in-person services can resume.
Consent*
I have been advised of all the potential risks, consequences and benefits of virtual music therapy services. My music therapist has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all of my questions have been answered. I understand the written information provided above.
Signature:*
Date:*
MM slash DD slash YYYY
If signed by person other than client, provide name and relationship to client:
Name & Title of person obtaining telephone or video-conferenced consent:
Witness is only required if consent is obtained by telephone or video-conferencing.
Date:
MM slash DD slash YYYY

Consent for Virtual Music Therapy Services

Authorization and Consent