top of page
A person uses an index finger on a tablet screen while seated at a white desk with a dual white monitor setup and white keyboard, representing the accessible and secure telehealth services, service options, and methods of submitting administrative forms and acknowledgments available through Availia TeleHelp PLLC in Spokane and Washington State.

Telehealth Safety Plan

Required for all telehealth clients.

Provides your location and emergency contact information so we can respond appropriately

if needed during a session.

Please Note:

This form is required for all clients receiving services via video.

​

Complete this form before your first telehealth session or bring it to your appointment.

​

If your primary session location changes at any point during your services,

please complete a new form and submit it before your next session.

Availia Client Information:

Date of Birth
Month
Day
Year

Emergency Preparedness:

Client Acknowledgments

I understand that I am responsible for providing my physical location at the start of any telehealth session conducted from a location other than the address listed above, and that in the event of an emergency during a telehealth session, my provider may contact emergency services at my reported location. I further acknowledge my access to toll-free support for Crisis Emergencies @ 988 and Local Emergency Services @ 911.


Availia TeleHelp PLLC and signee agree that any digital signature may serve the full legal effect and function of a handwritten signature.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
bottom of page