LifeStance Telehealth Consent

Updated: September 24, 2025

1. Scope of Consent
   I consent to receive all telehealth services provided to me by LifeStance Health and its affiliates and subsidiaries (“LifeStance”).
2. Definition of Telehealth
   I understand that telehealth is the use of virtual audio and video mediums to provide remote therapy, medical management, and other mental health care services. Such care may be provided by doctors, advanced practitioners, nurses, therapists, counselors, social workers, and other licensed mental health professionals.
3. Technology and Security
   I understand that my LifeStance Clinician will provide therapy and treatment (referred to in this form as a Telehealth Appointment) via synchronous and/or asynchronous telecommunications technologies, including remotely via the Internet using a web or network-based audio-video platform. I understand that the telehealth platform will incorporate network and security protocols to protect my information and that the platform itself hosts the software but does not provide medical advice.
4. Purpose of Services
   I understand that my Telehealth Appointment and other telehealth services may be for therapy, diagnosis, continuity of care, treatment, testing, medication management, or clinical consultation deemed necessary by my licensed LifeStance treating provider (LifeStance Clinician).
5. Provider Credentials, Benefits, and Risks
   If requested, I will be provided with information regarding my LifeStance Clinician(s)’ license type, number and their state location. I understand the benefits of telehealth, including improved access to care, but I also acknowledge the risks, such as technical failures or the potential need to reschedule if the transmitted information is inadequate.
6. Booking Telehealth Appointments
   To ensure compliance with licensing regulations, you must only book appointments with clinicians who are licensed in your state of residence, as our clinicians cannot initiate care or see new patients residing in states where they are not licensed. For military personnel and their dependents, you must book clinicians licensed in your state of legal residence (the state you claim as your permanent home), not necessarily your current duty station or home of record. Our clinicians cannot initiate care for patients residing in states where they are not licensed, and incorrect bookings based on location may result in a no-show or cancellation fee.

7. Acknowledgements Regarding the Telehealth Appointment
   I understand that during my Telehealth Appointment:
   • Details of my medical, clinical, and mental health history may be discussed with me and/or other health professionals.
   • All confidentiality and privacy protections granted to me by state and federal laws apply to my care.
   • Industry-standard security protocols are in place to safeguard my information.
   • There may be security and privacy risks associated with Internet-based communications.
   • There are benefits and limitations compared to a traditional in-person visit.
   • Either my LifeStance Clinician or I can discontinue the Telehealth Appointment if the remote communication is deemed inadequate.
   • To maintain my privacy, I am responsible for ensuring my viewing and listening area is private.
   • To ensure my safety and also support my ability to fully engage during the telehealth appointment, I understand that I should not be actively driving during the appointment.
   • LifeStance services are not intended for and should not be used for urgent or emergency situations.
     • In a medical emergency, I will call local authorities (9-1-1), the National Mental Health Line (9-8-8), or go to your nearest emergency room.
   • There is the possibility of the denial of insurance benefits for telehealth encounters
   • My telehealth encounters may not be recorded by the patient without express consent by both parties, regardless of other potential state laws to the contrary.
   • My LifeStance Provider may advise me to seek immediate treatment and, in an emergency, may provide my details to local authorities to assist me.
   • It is my duty to inform my healthcare provider of electronic or in-person interactions regarding my care that I may have with other healthcare providers.

THEREFORE, BY PARTICIPATING IN ANY LIFESTANCE TELEHEALTH APPOINTMENT, I ACKNOWLEDGE AND AGREE:

1. To engage in remote audio-visual communication with my LifeStance Provider.
2. To share my accurate physical location at the beginning of each Telehealth Appointment to ensure licensure compliance as well as provide information to my LifeStance Provider as to where emergency services can be dispatched in cases of an emergency.
3. To be in an environment conducive to participating in a LifeStance Telehealth Appointment.
4. That there are potential risks associated with telehealth technology, including interruptions, unauthorized access and technical difficulties, and neither LifeStance nor my healthcare provider will be liable for technological failures and no results can be guaranteed.
5. That my healthcare provider or I may unilaterally choose to discontinue the telehealth encounter if it is determined the technology is not appropriate under the circumstances.
6. That I have the right to withhold or withdraw my consent to the use of telehealth and/or telehealth services during my care at any time, without affecting my right to be referred for future care or treatment from a qualified provider who provides in-person care.
7. To a variety of alternative methods of health care may be available to me from other healthcare providers, such as an in-person encounter in lieu of a telehealth encounter, and I may choose one or more of those options at any time from a provider who may, or may not, be affiliated with LifeStance.
8. That a Telehealth Appointment may involve electronic communication of my personal healthcare information to other healthcare practitioners who may be located in other areas, including out of state or internationally when appropriate for providing me with care that I request.
9. That all existing confidentiality protections apply to telehealth encounters, and I have the right to access all healthcare information related to telehealth encounters and to receive copies of such information at cost upon request.
10. That there will be no further dissemination of any of my protected health information to other entities without my further written consent, or as otherwise permitted by law
11. To people other than my healthcare provider may be present in order to facilitate the telehealth consultation, and I will be informed of their presence.
12. That I have the right to access my designated health records in accordance with applicable state and federal patient privacy laws, and all records will be maintained in a manner that complies with state and federal patient privacy laws.
13. That when using technology to facilitate healthcare delivery, there may be cultural or language differences that may affect the delivery of services.
14. That there is the possibility of the denial of insurance benefits for telehealth encounters, and I understand that I may be responsible for co-payments, deductibles, or other charges.
15. That I understand that some parts of an exam involving physical or laboratory tests may be referred out and/or conducted by a third-party facility.
16. That I acknowledge that I have received a copy of my LifeStance Provider’s Notice of Privacy Practices, available via the website.
17. That I have read, understand, and agree to LifeStance’s Patient Services Agreement.
18. That I consent to my LifeStance Provider contacting me at the phone numbers or email addresses I provide, including by unencrypted text messages or emails. I understand and accept the risks of using unencrypted communications and know I can opt out as described in the Online Privacy Policy, which I have read and agree to.
19. That I have read and understand the disclosures set forth for the state in which I am located, as detailed in the State Disclosures / Notices as provided below.
20. Thank I understand I have the ability to ask my LifeStance Provider questions about this appointment. If my questions are not answered satisfactorily, I have the right to terminate the appointment.

STATE DISCLOSURES / NOTICES

I have reviewed and agreed to the following state-specific consent when receiving Telehealth Services in the following applicable state:

• Alaska: You understand your primary care provider may obtain a copy of your records of your telehealth encounter. (Alaska Stat. § 08.64.364). You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here.
• Arizona: You acknowledge that your telemedicine consultation is protected by all applicable patient confidentiality laws of Arizona per A.R.S. § 12-2292. You further acknowledge that any reports generated from this consultation will be included in your official health record as defined in A.R.S. § 12-2291. Finally, you understand that any images or information that could identify you cannot be used for research or education without your explicit permission, except as otherwise required or permitted by state or federal law (Ariz. Rev. Stat. Ann. § 36-3602).
• California: You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment.
• Colorado: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here.
• Connecticut: You understand that your primary care provider may obtain a copy of your records of your telehealth encounter. (Conn. Gen. Stat. Ann. § 19a-906). At the time of your first telehealth interaction, your provider will inform you concerning the treatment methods and limitations of treatment using a telehealth platform and obtain your consent to provide telehealth services. Your provider will document such notice and consent in your health record.
• D.C.: You have been informed of alternate forms of communication between you and a physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10)
• Delaware: You have the right to receive a disclosure of the fee schedule for telehealth services prior to the start of your visit.
• Georgia: You have received clear and accurate instructions on the steps to take if you need emergency care related to this treatment. (Ga. Comp. R. & Regs. 360-3-.07(7))
• Idaho: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here.
• Illinois: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here.
• Indiana: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here.
• Iowa: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here.
• Kansas: You acknowledge that, provided you have an established primary care or treating physician, the telemedicine provider may be required to forward a summary of the treatment rendered during this encounter to that physician within three (3) business days. (Kan. Stat. Ann. § 40-2,212(2)(d)(1)(A))
• Kentucky: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here.
• Louisiana: You acknowledge and understand the purpose of any additional healthcare providers who may be present during the consultation alongside your treating provider. (46 La. Admin. Code Pt XLV, § 7511)
• Maine: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here, or, the Maine Board of Osteopathic Licensure’s website, here.
• Maryland: Maryland law requires additional protections for telehealth visits, including identity verification, emergency planning, and privacy safeguards. Your provider will confirm your location at each telehealth visit to ensure compliance with licensing requirements. You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here.
• Michigan: You have been informed that if you want to register a formal complaint about a provider, you should visit the Michigan Department of Licensing and Regulatory Affairs (LARA) website at michigan.gov/lara or call 517-241-0199. Michigan law requires that telehealth services comply with the same standard of care as in-person services. (Mich. Comp. Laws § 333.16285)
• Missouri: You have been informed that if you want to register a formal complaint about a provider, you should visit the Missouri Division of Professional Registration website at pr.mo.gov or call 573-751-0293. (Mo. Rev. Stat. § 191.1145)
• Montana: You understand that telehealth services are subject to the same standards of care as in-person services. You have been informed that if you want to register a formal complaint about a provider, you should visit the Montana Board of Medical Examiners website at boards.bsd.dli.mt.gov/medical-examiners/ or call 406-841-2364. (Mont. Code Ann. § 37-3-342)
• Nebraska: You acknowledge your right to access all medical information generated from this telehealth consultation, consistent with laws governing health records. You further understand that any images or data that could identify you will not be shared for research or with other organizations without your explicit written permission. Finally, you are aware of your right to request an in-person consultation immediately following this telehealth session, and you will be notified if that option is unavailable. (Neb. Rev. Stat. Ann. § 71-8505; 471 Neb. Admin. Code § 1-006.05)
• Nevada: Nevada law requires that telehealth providers obtain patient consent before providing telehealth services and disclose the limitations of those services. You have the right to request in-person services. You may file a complaint with the Nevada State Board of Medical Examiners at medboard.nv.gov or 775-688-2559. (Nev. Rev. Stat. § 629.515)
• New Hampshire: You acknowledge that, provided you have an established primary care or treating physician, the provider may forward your health records to your primary care or treating provider. (N.H. Rev. Stat. § 329:1-d)
• New Jersey: You acknowledge your right to obtain a copy of your health records. You also understand that a summary of this encounter may be sent to your primary care provider or other treating physician, and that, at your request, it can be forwarded to additional healthcare providers.
• New Mexico: New Mexico law requires telehealth providers to obtain verbal or written informed consent before providing telehealth services. Your consent will be documented in your medical record. You may file a complaint with the New Mexico Medical Board at nmmb.state.nm.us/ or 505-476-7220. (N.M. Stat. Ann. § 24-25-5)
• North Dakota: You have been informed that telehealth services in North Dakota are subject to the same professional standards as in-person care. You may file a complaint with the North Dakota Board of Medicine: here or 701-328-6500. (N.D. Cent. Code § 43-17-43)
• Ohio: You understand that the telehealth provider may forward your health records to your primary care or treating provider. (Ohio Admin. Code 4731-11-09(C))
• Oklahoma: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here, or the Board of Osteopathic Examiners can be found at: here.
• Oregon: Oregon law requires written informed consent before telehealth services are provided. Your provider will document your consent in your health record. You may file a complaint with the Oregon Medical Board at oregon.gov/omb or 971-673-2700. (ORS § 442.015)
• Pennsylvania: You understand that you may be asked to confirm your consent to behavioral health or tele-psych services.
• Rhode Island: You have been informed about the appropriate uses of email and text messaging for communication with your provider, as well as situations that require an office visit or a more secure method of contact. You have discussed security protocols, including data encryption and password protection, along with the potential privacy risks involved. You acknowledge that not adhering to these guidelines may result in the discontinuation of electronic communication with your provider. (Rhode Island Medical Board Guidelines)
• South Carolina: You understand your health records may be shared in accordance with applicable law and regulation to other treating health care practitioners. (S.C. Code Ann. § 40-47-37)
• South Dakota: You acknowledge that you have received all necessary disclosures concerning the methods of treatment and their potential limitations. You have discussed with your provider the diagnosis, the basis for this diagnosis, and the associated risks and benefits of all treatment alternatives. Your provider will verify and authenticate your location and identify you to the extent reasonable, disclose and validate their identity and credentials, and provide you with a visit summary or consult note. (S.D. SB136)
• Tennessee: You understand that you may request an in-person assessment before receiving a telehealth assessment if you are a Medicaid recipient.
• Texas: You understand that your health records may be sent to your primary care physician. (Tex. Occ. Code Ann. § 111.005). You have been informed of the following notice:
  • NOTICE CONCERNING COMPLAINTS – Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353. For more information, please visit our website at www.tmb.state.tx.us.
  • AVISO SOBRE LAS QUEJAS – Las quejas sobre médicos, así como sobre otros profesionales acreditados e inscritos del Consejo Médico de Texas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugía, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353. Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us.
• Utah: You acknowledge that you have received and understand the following information:
  • The details of any fees specific to telehealth services and the associated payment process.
  • The parties to whom your health information may be disclosed and the purposes for such disclosures, including the consents required for releasing identifiable data to third parties.
  • Your rights regarding the privacy and security of your health information.
  • The appropriate uses and limitations of this telehealth service, including procedures for emergency situations.

  You understand that your provider utilizes security measures that comply with industry standards and applicable laws to protect your information. However, you have been advised that potential privacy risks exist, and technical failures could result in data loss, for which you agree to hold the provider harmless. You have been provided with the provider’s website and contact details. You were able to select your preferred provider and pharmacy to the extent possible. You also understand your ongoing rights to: access and amend your personal health information; contact your provider for follow-up care; request a copy of your health records from this encounter; and have your records transferred to another provider. (Utah Code Section 26-60-102(8)(b)(ii) and Utah Admin. Code 156-1-602)

• Vermont: You acknowledge receipt of details regarding the security measures (e.g., data encryption, password protection) and inherent privacy risks associated with telemedicine services. Notwithstanding these measures, you agree to hold your provider harmless for information lost due to technical failures. You hereby provide express consent for the disclosure of your patient-identifiable information to a third party. (Vt. Stat. Ann. § 9361). You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, Vermont Medical Practice Board: here, or the Board of Osteopathic Examiners can be found: here.
• Virginia: You understand the security steps taken to protect your telemedicine visits, such as encryption and passwords, and you are aware that privacy risks can still occur. You will not hold your provider responsible for information lost because of technical problems. You give your clear permission for your provider to share information that identifies you with a third party. (Virginia Board of Medicine Guidance Document 85-12)
• Washington: You have been informed about the appropriate uses of telehealth services, including the limitations and treatment methods. Your provider will verify your location, disclose their credentials, and obtain your consent before providing telehealth services. (WA SB 5254)
• Wisconsin: Wisconsin law requires that telehealth providers meet the same standard of care as in-person providers and maintain accurate records of telehealth interactions. You may file a complaint with the Wisconsin Medical Examining Board at dsps.wi.gov or 608-266-2112. (Wis. Stat. § 448.9725)
• Wyoming: Wyoming law permits licensed practitioners to provide healthcare services via telehealth subject to applicable licensing requirements and standards of care. You may file a complaint with the Wyoming Medical Board at wyomedboard.wyo.gov or 307-778-7053. (Wyo. Stat. Ann. § 33-26-102)