Consent for Mental Health Support Services

Last Updated: March 4, 2023

By accepting (“click the link”), you, as a registered/authorized user (“you” or “User”), indicate that you have read, understand, accepted, and become legally bound to the following terms of this Consent for Mental Health Support Services Agreement (the "Consent Agreement") between Counslr, Inc. (“Counslr” or “Company”), where applicable, a mental health professional (“Counselor”) providing online (telehealth) services on the website, mobile apps or other electronic means controlled by Counslr (collectively, the “Platform”), and you for the purpose of providing you, someone under the age of 18 years of age or who lacks the capacity to grant consent (“Minor User”), or other person over the age of 18 years (“Other User”, and with you and Minor User, collectively “Users”) with Support Services (as defined below) administered via a telehealth platform (collectively, the “Services”). By engaging the Services, you further agree that you have read, understand and consent to this Consent Agreement:

This Agreement governs and applies to your interactions with the “Counselors” on the Counslr Platform to receive Support Services:

Definitions.

User is an employee, family member of an employee or student of a Sponsoring Organization receiving Support Services from a Counselor on the Platform.
Counselor is an independent mental health professional, who has an agreement with Counslr allowing the Counselor to provide Support Services for Users through the Platform.
Counslr is the owner and operator of the Platform and is not a Counselor or other provider of Support Services or any healthcare services.
Private Information is your personally identifiable information (“PII”), including protected health information (“PHI”), as defined under the Health Insurance Portability and Accountability Act (HIPAA), and other private information as defined in (i) the Family Educational Rights and Privacy Act of 1974, as amended, and its regulations (“FERPA”), (ii) to the extent applicable, personal information of online persons under age 13, pursuant to the Children’s Online Privacy Protection Act of 1998, as amended, and its regulations (“COPPA”); and (iii) state-specific health information confidentiality and privacy laws, provided to Company or Counselor or developed while receiving the Services.
Sponsoring Organization means an entity or individual that has entered into an agreement with Counslr to provide access to the Platform for its employees and their families or students to receive Support Services without charge to the User.
Support Services means telehealth mental health support services provided by Counselors to Users through the Platform. Support Services are designed, intended, and offered ONLY to provide education, goal setting, accountability, referral to resources, problem solving, skills training, and help with decision making, and do not constitute the practice of medicine, therapy or any other health care service that must be delivered through a licensed clinician in the State where User is located.

Eligibility Requirements and Acknowledgements

You or your authorized representative hereby consents to engaging the services of the Counselor to provide Support Services to the User on the Counslr Platform.
You or Other User are eighteen (18) years of age or older.
If the recipient of Services is a Minor User, you are the parent, legal guardian or authorized representative of the Minor User or the Minor User to the extent permitted by applicable law, and:

You understand and agree that you are granting your parental or other legal consent for Minor User to access the Platform and to receive Services from a Provider.
You understand and agree that the Minor User will be under your supervision when he/she/they is accessing the Platform and receiving Services.
You understand and agree that if the Minor User is between the age of 13 and 18 years old you grant consent for the Minor User to access the Platform and receive Services with or without your supervision.
You understand, agree and represent on behalf of the Minor User that by accessing the Platform and/or engaging the Services, the Minor User consents to receiving Services and agrees to be bound by the terms of this Agreement.

You are an employee, family member of an employee or student of a Sponsoring Organization.
You understand and agree Support Services consist of mental health support services only, and Support Services are not therapy, a medical service, or a substitute for medical services or therapy, and may not be as complete as face-to-face services. You also understand that if your Counselor believes you would be better served by another form of intervention (e.g., face-to-face services) you will be provided information on available mental health providers who can provide such services in your area. Finally, you understand that there are potential risks and benefits associated with any form of support services, and that despite your efforts and the efforts of your Counselor, your situation may not improve, and in some cases may even get worse.
You understand and accept your interaction with the Counselor is not intended to form a clinician-client relationship on the Platform. By answering questions, Counselors do not intend to form, and do not form, any clinician-client relationship, and the contents of any exchange of information may not be protected by any clinician-client privilege.
You understand and agree to interact with the Counselor only through your account established on the Platform.
You understand and accept Support Services will occur primarily through interactive texting between the User and the Counselor. You agree that by using the Platform, you expressly authorize Counslr and the Counselors to communicate with you via electronic means, such as email, text, telephone, or chat, as determined appropriate by Counslr. You understand that such electronic communication is not a secure form of communication, and you understand there are risks involved in such communications, such as unauthorized access or inadvertent disclosure of your information.
You understand and agree the information disclosed by you during the course of your sessions are generally confidential, however, there are both mandatory and permissive exceptions to confidentiality, including but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; expressed threats to harm or kill yourself; and where you make your mental or emotional state an issue in a legal proceeding. You understand and agree that Counslr or a Counselor may also disclose your Private Information to your designated emergency contact to prevent harm to you or someone else.
You understand and agree the Private Information that you provide to Counslr or Counselors, or that Counslr or Counselors collect about you through your access to and use of the Platform is subject to Counslr Privacy Policy (available at www.counslr.com/privacy).
You understand and agree to reaching out to and/or locating you, either ourselves or using the appropriate authorities, if either we or a Counselor have a good reason to believe that you or any other person may be in danger.
You understand and agree Counslr may de-identify and use Private Information in any manner permitted by law, as set forth in the Privacy Policy.
You understand and agree for purposes of providing Support Services on the Platform, the Counslr platform is fully HIPAA-compliant and follows stringent data privacy laws and rules, including FERPA, COPPA, state-specific health information confidentiality and privacy laws.
You understand and agree that Counslr will and the Counselor may maintain records of your Support Services sessions and related material for no less than seven (7) years.
You understand that there are risks and consequences from Support Services, including, but not limited to, the possibility, despite reasonable efforts on the part of Counslr or your Counselors, that: the transmission of your personal information could be disrupted or distorted by technical failures; the transmission of your personal information could be interrupted by unauthorized persons; and/or the electronic storage of your personal information could be accessed by unauthorized persons.
You understand that the Counselors are independent mental health professionals and are not employees, agents or representatives of Counslr, and the cost for providing Support Services will be paid for by the Sponsoring Organization.
While Counslr makes commercially reasonable efforts to ensure the Platform’s reliability and accessibility, you understand and agree no platform can be 100% reliable and accessible and so neither Counslr nor your Counselor can guarantee that access to the Platform will be uninterrupted or that it will be accessible, consistent, timely or error-free at all times. In the event of a failure of the Counslr platform, you can contact Counslr at hello@counslr.com in order to receive information on available local mental health providers during the period when the Counslr platform is unavailable.
You agree to receive notices or other communications regarding the Counselor by email to the email address that Counslr has on record for you, by regular mail or by posting it online. The date of sending shall be deemed the date on which such notice is given. Notices sent to Counslr must be delivered by email to hello@counslr.com.
You understand and agree this Consent Agreement and your relationship with Counselor shall be interpreted solely in accordance with the laws of the State of New York, excluding any rules governing choice of laws, and the exclusive venue for any action or proceeding arising out of relating to this agreement or your relationship with your Counselor, regardless of theory, shall be the U.S. District Court for the Eastern District of New York, or the state courts located in Nassau County in New York. Further, you consent to the personal jurisdiction of the aforementioned courts and hereby waive any objection to the exercise of jurisdiction by the aforementioned courts.
You understand and agree Counslr may change this Consent Agreement by posting modifications on the Platform. Unless otherwise specified by Counselor, all modifications shall be effective upon posting. Therefore, you are encouraged to check the terms of this agreement frequently. By using the platform after the changes become effective, you agree to be bound by such changes to the agreement. If you do not agree to the changes, you must terminate access to the platform and participation in its services.
You understand and agree this Consent Agreement, including any other agreements or policies referenced herein, constitutes the entire agreement between the Counselor and you, specifically this Consent Agreement is made part of and incorporated into the Terms of Use Agreement between Counslr and you, and you have read the Terms of Use Agreement to understand your responsibilities when using Support Services and the Platform.
If any provision of this Consent Agreement is held by a court of competent jurisdiction to be illegal, invalid, unenforceable, or otherwise contrary to law, the remaining provisions of this agreement will remain in full force and effect.
You understand and agree that this Consent Agreement shall be fully transferable and duplicable to apply to any Counselor you select on the Platform, and you may receive Support Services from one or multiple Counselors without the need for you to sign a new Consent Agreement.
You understand and agree you have the right to withhold or withdraw consent at any time and cease participation with any Counselor on the Counslr platform. If consent is withheld or withdrawn, you may request a referral to a local mental health provider. You further understand and agree that Counselor may terminate this Consent Agreement and cease providing Support Services at any time by providing you with notice.

You have read and understand the terms provided above. You have had the opportunity to ask questions about the Support Services to be provided and all of your questions have been answered to your satisfaction.

You may request a downloadable and printable copy of this form, either now or at any point in the future.

Before any exchange of your private information with any other counselor can be made, you must agree to our Authorization to Exchange Private Information: www.counslr.com/auth-exchange-pii