Informed Consent

Jay Ostrowski is a:

Licensed Professional Counselor,
Licensed Professional Counselor Supervisor,
National Certified Counselor
Distance Credential Counselor

Jay has more than fifteen years experience helping children, adolescents and adults with mental and emotional issues. He holds a Bachelors Degree in Psychology from Baylor University and Masters degree in Counseling Psychology from Trinity International University. He provides Solution-Focused Therapy and Cognitive-Behavioral Therapy in an outpatient setting, telephonic counseling and counseling in secure environments online. Sessions are by appointment only.

Engaging Jay Ostrowski in any counseling related communication or paid counseling session is considered consent to the following:

  1. 1. I hereby consent to engaging in telemedicine with John Ostrowski (“Jay”) for counseling services.
  2. 2. I understand that “telemedicine” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications.
  3. 3. I understand that it is not advisable to use telemedicine for crisis situations.
  4. 4. I understand that telemedicine also involves the communication of my medical/mental information, both orally and visually, to health care practitioners located in Michigan or South Carolina.
  5. 5. I understand that I have the following rights with respect to counseling:
  6. 6. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
  7. 7. The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed or implied threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.
  8. 8. I understand that the dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my written consent.
  9. 9. I understand that there are risks and consequences from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychotherapist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
  10. 10. I understand that telemedicine based services and care may not be as complete as face-to-face services. I also understand that if my counselor believes I would be better served by another form of psychotherapeutic services (e.g. face-to-face services) I will be referred to another provider who can provide such services in my area.
  11. 11. I understand that there are potential risks and benefits associated with any form of psychotherapy and counseling, and that despite my efforts and the efforts of my psychotherapist, my condition may not be improve, and in some cases may even get worse.
  12. 12. I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured.
  13. 13. I understand that despite security measures, internet security cannot be guaranteed by Jay Ostrowski.
  14. 14. I understand that I have a right to access my medical information and copies of medical records in accordance with Michigan or South Carolina law.
  15. 15. If you are a minor, your parent or legal guardian must provide written consent prior to treatment.
  16. 16. Jay Ostrowski reserves the right to refer clients to more appropriate therapists or therapeutic venues and may not participate in communication that he deems not therapeutic.

I have read and understand the information provided above. I have discussed it with my psychotherapist, and all of my questions have been answered to my satisfaction.


For Michigan Residents:
To file a complaint about counseling services received you may contact:
Michigan Department of Community Health (517) 373-9196
Health Regulatory Division
P.O. Box 30670
Lansing, MI 48909