Last Updated: March 4, 2023
By accepting (“click the link”), you, as a registered user (“you” or “User”), indicate that you have read, understand, accepted, and become legally bound to the following terms of this Authorization to Exchange User’s Private Health Information (the "Authorization”) between Counslr, Inc. (“Counslr” or “Company”), mental health professionals (“Counselors”) providing online (telehealth) services on the website, mobile apps or other electronic means controlled by Counslr, Inc. (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”).
This Authorization governs and applies to your interactions with the Counselors on the Counslr Platform to receive Support Services:
- User is an individual designated by 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 to certain individuals designated by the entity or individual 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.
- Acknowledgements and Authorizations
- 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, and:
- You understand, agree and represent on behalf of the Minor User to authorize the exchange of Private Information and agrees to be bound by the terms of this Authorization.
- You understand and agree User will be interacting with one or more Counselors on the Platform.
- You understand and agree User’s interactions with Counselors, which may contain Private Information, will be recorded, the contents documented, and stored in a repository maintained by Counslr and possibly by the Counselor, separately.
- YOU AUTHORIZE COUNSLR AND THE COUNSELORS WITH WHICH YOU INTERACTED TO RELEASE AND EXCHANGE YOUR PRIVATE INFORMATION WITH OTHER COUNSELORS ON THE COUNSLR PLATFORM AND QUALIFIED PERSONS OF THE SPONSORING ORGANIZATION AND TO RELEASE AND EXCHANGE YOUR PRIVATE INFORMATION WITH OTHER PARTIES DESIGNATED BY YOU IN WRITING TO COUNSLR AND TO YOUR DESIGNATED EMERGENCY CONTACT TO PREVENT HARM TO YOU OR SOMEONE ELSE.
- You understand and agree you have the right to revoke this authorization at any time by communicating such revocation in writing to Counslr. You understand and agree that such revocation shall not apply to any actions that have already been taken based on this Authorization.
- You understand and agree this Authorization is voluntary and applies only to your participation on the Platform.
- You understand and agree that the receipt of Support Services will not be conditioned upon you entering into this Authorization.
- You understand and agree this Authorization will expire on the date on which you terminate your participation on the Platform by contacting Counslr at email@example.com and indicating in writing your desire to terminate participation.
- You understand and agree this Authorization does not authorize anyone to share your Private Information with any other person or entity unless otherwise authorized by you in a separate writing and except as may be required or permitted by law.
- You understand and agree the Private Information disclosed under this Authorization might be redisclosed by the recipient, and this redisclosure may no longer protect the confidentiality of your Private Information.
- Authorization to Use Unprotected Resources
By engaging the Services, you further agree that you have read, understand and consent to this Authorization.
You may request a downloadable and printable copy of this form, either now or at any point in the future.
Please ensure you have also reviewed our Consent for Mental Health Support Services: https://www.counslr.com/telehealth-support-consent