Change in Entropy Hypnotherapy
Website: https://www.change-in-entropy.com/
Effective Date: March 17, 2026
Last Updated: March 17, 2026
Practice Contact Information
Change in Entropy Hypnotherapy
2862 Change Street, Unit A
Los Alamos, NM 87544
Email: [email protected]
Phone: (907) 278-1180
1. Patient Information
Patient Full Name: ________________________________________
Date of Birth: ____________________________________________
Address: _________________________________________________
Phone: _________________________________________________
Email: _________________________________________________
2. What Telehealth Means
Telehealth means services delivered using electronic communication technology, such as secure video, audio, or other remote communication tools, instead of an in-person visit. In New Mexico, telehealth includes interactive audio, video, data communications, and store-and-forward technologies, and a patient’s residence may be the originating site for telehealth services.
For this practice, telehealth may include:
video sessions
phone sessions, where appropriate
secure messaging or portal communications for administrative purposes
remote follow-up communications related to care
3. Purpose of This Consent
This form explains the nature of telehealth services, the potential benefits and risks, technology and privacy considerations, emergency procedures, and your rights and responsibilities.
By signing this form, you acknowledge that you have read and understood this Telehealth Consent and agree to receive telehealth services from Change in Entropy Hypnotherapy under the terms below.
4. Potential Benefits of Telehealth
Possible benefits of telehealth may include:
improved convenience
easier access to services
reduced travel time
greater scheduling flexibility
continuity of care when an in-person session is not practical
Benefits are not guaranteed.
5. Possible Risks and Limitations of Telehealth
You understand that telehealth has possible risks and limitations, including:
interruptions, delays, or technical failures
reduced ability to observe nonverbal communication
reduced ability to respond in person during a crisis or emergency
privacy risks if your environment, device, internet connection, or communications are not secure
occasional limitations in service quality compared with an in-person session
New Mexico counseling best-practice guidance specifically recommends addressing the risks, benefits, limitations, confidentiality concerns, emergency procedures, and alternative communication methods in the telehealth consent form.
6. Technology and Privacy
If HIPAA applies to your care, telehealth services are provided using technology chosen to support HIPAA compliance. HHS states that telehealth services by covered providers and health plans must comply with the HIPAA Rules, and covered providers must use technology vendors that will enter into appropriate business associate agreements when required.
Even with reasonable safeguards, no electronic communication system is completely risk-free. You understand that:
technology failures can happen
unauthorized access may occur despite safeguards
your privacy may be affected by people near you, your device settings, or your internet connection
To help protect your privacy, you agree to:
attend telehealth sessions from a private location when possible
use a secure device and internet connection when possible
wear headphones if helpful for privacy
avoid participating in sessions while driving or in public places unless necessary and safe
HHS guidance also recommends discussing the patient’s responsibilities for privacy during telebehavioral health visits, including finding a private location and using headphones when appropriate.
7. Recording Policy
Telehealth sessions may not be audio-recorded, video-recorded, photographed, screen-recorded, or otherwise captured by you or by anyone else without prior written consent from Change in Entropy Hypnotherapy.
The practice will not record telehealth sessions without your separate written permission, unless required by law.
8. Emergency and Safety Procedures
Telehealth is not emergency care and is not appropriate for every situation.
You understand and agree that:
if you are experiencing a medical emergency, mental health crisis, thoughts of self-harm, thoughts of harming others, or any urgent safety concern, you should call 911, go to the nearest emergency room, or contact an appropriate crisis resource immediately
telehealth may be stopped if the practitioner believes that you need a higher level of care, an in-person evaluation, or emergency assistance
at the start of a telehealth session, you may be asked to confirm your current physical location and a callback number in case the connection is lost or emergency help is needed
New Mexico counseling best-practice guidance recommends establishing emergency protocols for teletherapy and addressing emergency procedures in the consent form.
9. Alternative Communication Methods
If there is a technology failure during a session, we may attempt one or more of the following, as appropriate:
reconnect by the same platform
continue by phone
reschedule the session
use another approved secure method, if available
New Mexico best-practice guidance specifically recommends addressing alternative communication methods in the consent form.
10. Observers and Other People Present
If anyone other than you and the practitioner will be present, observing, or listening during a telehealth session, you will be informed and your consent will be obtained at the start of the session. HHS telehealth guidance recommends telling the patient if anyone is observing the visit and obtaining consent at the start.
You also agree to inform the practitioner if any other person is present with you during the session.
11. Suitability of Telehealth
Telehealth may not be appropriate for all services, all conditions, or all situations. The practitioner may determine that:
an in-person session is preferable
telehealth should be postponed
another provider or level of care is more appropriate
services should be discontinued for safety, legal, technical, or clinical reasons
The New Mexico Telehealth Act does not expand a provider’s scope of practice or authorize services in a manner not otherwise allowed by law.
12. Client Responsibilities
By signing this form, you agree to:
provide accurate contact and location information
notify the practice if your technology is not working
participate from a setting that is as private and distraction-free as reasonably possible
avoid attending sessions while operating a vehicle or machinery
notify the practitioner of any urgent safety concern
understand that telehealth may be interrupted or rescheduled if privacy, safety, or connection quality is inadequate
13. Fees, Billing, and Financial Policies
Telehealth sessions are subject to the practice’s Financial Policy, cancellation policy, and any other signed client agreements.
You remain responsible for fees associated with telehealth services unless otherwise agreed in writing.
14. Consent to Telehealth Services
By signing below, you acknowledge and agree that:
you have read and understand this Telehealth Consent;
you have had the opportunity to ask questions;
you understand the potential benefits, risks, and limitations of telehealth;
you understand the privacy and technology-related considerations;
you understand the emergency and alternative communication procedures;
you consent to receive telehealth services from Change in Entropy Hypnotherapy.
15. Consent Preferences
Please initial all that apply:
_____ I consent to telehealth sessions by secure video.
_____ I consent to telehealth sessions by phone when video is unavailable or not clinically necessary.
_____ I understand that telehealth may not be appropriate for emergencies or crisis situations.
_____ I understand that I may withdraw my consent to telehealth at any time by notifying the practice, although this will not affect services already provided.
16. Patient Signature
Patient Name: ___________________________________________
Patient Signature: ________________________________________
Date: __________________________________________________
17. Personal Representative, if Applicable
Name of Personal Representative: ____________________________
Relationship to Patient: ___________________________________
Authority to Act for Patient: ________________________________
Signature of Personal Representative: ________________________
Date: __________________________________________________
18. Practice Representative
Practice Representative: ___________________________________
Signature: ______________________________________________
Date: __________________________________________________