Online Psychotherapy/Hypnotherapy Consent Form


Online Therapy: It is expected that I will benefit from online therapy as all or part of psychotherapy, but there is no guarantee. Therapy is conducted using interactive audio and/or video and/or email. Online-based services as care may not be appropriate for my need. If it is assessed that face-to-face is more appropriate, it will be discussed.

Online Therapy and Limitations: I understand that online therapy includes the practice of healthcare delivery, consultation, hypnotherapy, and education using interactive audio and video communication.

I understand that online sessions have limitations compared to in-person sessions, among those being the lack of “personal” face-to-face interaction, and the lack of body language cues in the therapy process.

I understand online therapy is not for me if I am in a high-risk category, including severe mental illness or highly acute symptoms such as psychosis. 

Procedures for technical difficulties or Internet disruptions: As a client of Art of Change Therapy Counseling, I understand that online therapy is technical in nature and that problems with the Internet may occur. If something beyond our control disrupts the connectivity of our session, I will immediately try to video call the therapist again. The session will be rescheduled if the video call is repeatedly unsuccessful for 15-20 minutes.

Confidentiality: The information disclosed during the course of my therapy is confidential. Art of Change Therapy uses the most secure encrypted telemedicine system compliant with the highest HIPAA and HITECH  encryption. No personal information obtained will be disclosed without informed consent, except in circumstances of diminished capacity, children/young persons, urgent need, legal requirements and/or client or public safety.

Please note: 
Art of Change Therapy is not a 24/7 helpline; the therapist can’t promise an immediate response. If you feel suicidal outside of therapy time, please get in touch with hotline help in your country.

New Zealand –

This service is not appropriate for:

  • Young people under 13 years
  • Anyone under adult age, according to regulations of your respective country, without parental approval and guidance
  • People living in a place with low-quality or limited internet service
  • People who have difficulty operating a computer or mobile device

If you are in doubt, you are welcome to contact me to discuss it.

Payment Agreement: According to the sessions timeframe program agreed Online worldwide:

Bank transfer is possible for NZ to Etai Gilad

Cancellation Policy:

Please notify Art of Change Therapy of cancellation via email at least 24 hours before the session.

In case of non-attendance, the session will be reduced from the timeframe program.