Telehealth Across State Lines and a Suicidal Student
An LCMFT licensed only in Maryland began seeing a 20-year-old college student in person in Maryland for four sessions. The student returned to a Virginia campus and the therapist agreed to continue weekly video sessions. During the fifth video session, the student is alone in a dorm room in Virginia, reports passive suicidal ideation, shows fresh cuts on an arm, and says she has been drinking heavily. She refuses to go to the campus counseling center and asks the therapist not to call her parents. The therapist has the dorm address but no Virginia license, no written telehealth emergency plan, and has not verified the student's physical location at the start of prior sessions. The therapist is unsure whether continuing is permitted, whether a Maryland license covers the session, and what to do if the student becomes acutely suicidal during the call.
1. Can the therapist continue weekly video sessions while the client is physically in Virginia? What should the therapist do about licensure?
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Licensure generally follows the location of the client at the time of service. A Maryland LCMFT license does not automatically authorize telehealth into Virginia. The therapist should verify Virginia's rules for out-of-state providers and the client's physical location at each session. If Virginia allows only a temporary or emergency exception, the therapist should not continue routine weekly therapy without a Virginia license or a lawful exception. The therapist should not abruptly abandon the client. The therapist should explain the licensure issue, provide referrals to Virginia-licensed providers and campus counseling, offer short-term bridging sessions only if permitted, and document. If the client returns to Maryland for sessions, the Maryland license covers those sessions. The therapist should also check payer rules, because insurance may deny out-of-state services. The therapist should not rely on the client's parents being in Maryland or on the therapist's Maryland office as the location of service.
2. What should the therapist do in the current session to manage suicide risk and set up an emergency plan?
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During the current session, safety comes first. The therapist should keep the client on the video call, confirm the exact dorm address and phone number, and ask about the cuts, suicidal plan, means, and alcohol use. If the client is at imminent risk, the therapist should call 911 or campus police or security for a welfare check, stay on the line until help arrives if possible, and contact the emergency contact the client has authorized or the parents if necessary to prevent serious harm. The therapist should not promise not to call parents when there is imminent danger. The therapist should document the client's location, statements, actions taken, time, and people contacted. After the crisis, the therapist should create a written emergency plan with local resources, campus counseling, and a consent for emergency contacts. The absence of a Virginia license does not prevent emergency action to protect life; it does affect ongoing treatment.
3. If the client refuses referral and insists on continuing video sessions from Virginia, what should the therapist do to avoid abandonment?
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The therapist should not simply continue unlawfully. The therapist should explain the limits, offer to help transition to a Virginia-licensed provider, provide records upon authorization, and set a termination date. Termination is not abandonment if the therapist gives reasonable notice, referrals, and emergency resources. The therapist should document the client's refusal, the referrals given, and the safety plan. If the client is at high risk, the therapist should not terminate without ensuring a warm handoff; the therapist may need to involve campus counseling or emergency services. The therapist should also consult the Board or an attorney about whether any temporary interstate exception applies. The therapist should not misrepresent the client's location to an insurer or continue billing as if the client were in Maryland.