As a condition of participating in telehealth with Momentum Inc., I agree to the following:
· I have voluntarily chosen to receive treatment services from Momentum Inc.
· Momentum Inc. and I both have the right to terminate treatment at any time.
· Consultations will be conducted entirely via videoconferencing (Zoom).
· Clinicians are Board Certified Behavior Analysts (BCBAs) practicing in Rhode Island. BCBAs may not be licensed in my state of residence.
· Clinical guidance will be based solely on information provided by the client.
· Momentum Inc. disclaims and makes no promises or guaranties regarding the outcome of treatment.
· All client records and information will be maintained in accordance with applicable law. Momentum Inc. may disclose records and/or information without client consent in certain circumstances including but not limited to health oversight agencies, to prevent imminent harm to the client or others, as required by law or court order, and for a workers’ compensation claim.
· Momentum Inc. may release non-clinical information for the purposes of collecting payment owed for services rendered by Momentum Inc.
· The relationship with Momentum Inc. is governed by Rhode Island law and I consent to exclusive jurisdiction in the courts of Rhode Island.