Because of the pandemic, I am offering free therapy via Skype or Zoom. My hope is to give comfort to those struggling during this time.  Since all sessions are held online at this time the only Privacy Statement needed is for Telehealth.  There is nothing you need to sign.

Privacy Statement


A Privacy Statement is a central part of a psychotherapist's code of ethics. Psychotherapist's understand that for people to feel comfortable talking about private and revealing information, they need to know they can talk about anything they'd like, without fear of that information leaving the room.  Below are various Privacy Statements. While you do not need to sign anything for telehealth, the privacy laws are the same with some exceptions because of the technical plateform the sessions are being held. 

Telehealth informed consent form


I _______________________________(name of client) hereby consent to engage in telehealth with Dawn Mehalakis, MA, LMFT as part of my psychotherapy. I understand that “telehealth includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data and education using interactive audio, video, or data communications. I understand that telehealth also involves the communication of my mental health information, both orally and visually, to health care practitioners located in California only.

I understand that I have the following rights with respect to telehealth: 

  1. I have the right to withhold or withdraw consent at anytime without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
  2. The laws that protect the confidentiality of my mental health information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my therapy is confidential with the exception of my mandated reporting duties of child, elderly, and disabled abuse or neglect, or expressed threats of violence toward an ascertainable victim.
  3. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to researchers or other entities shall not occur without my written consent.
  4. I understand that there are risks and consequences from telehealth, including but not limited to, the possibility that the transmission of my mental health information could be disrupted or distorted by technical failures; the transmission of my mental health information could be interrupted by unauthorized persons, and/or the electronic storage of my mental health information could be accessed by unauthorized persons. 
  5. I understand that I may benefit from telehealth, but results cannot be guaranteed or assured.
  6. I understand that I have a right to access my mental health information and copies of mental health records in accordance with California law.

I have read and understand the information provided above. I have discussed it with my psychotherapist, and all of my questions have been answered to my satisfaction.