Informed Consent for Telepsychology This Informed Consent for Telepsychology contains important information focusing on doing psychotherapy using the phone or the Internet. Please read this carefully and let me know if you have any questions. When you sign this document, it will represent an agreement between us.Benefits and Risks of Telepsychology Telepsychology refers to providing psychotherapy services remotely using video conferencing. One of the benefits of telepsychology is that the client and clinician can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or clinician moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It is also more convenient and takes less time. Telepsychology, however, requires technical competence on both our parts to be helpful. Although there are benefits of telepsychology, there are some differences between in-person psychotherapy and telepsychology, as well as some risks. For example: Risks to confidentiality. Because telepsychology sessions take place outside of the therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. On my end I will take reasonable steps to ensure your privacy. But it is important for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation.Issues related to technology. There are many ways that technology issues might impact telepsychology. For example, technology may stop working during a session.Crisis management and intervention. In the event of a life-threatening emergency please call the office and speak with a support staff or follow the after hours prompts for contacting our answering service. Efficacy. Most research shows that telepsychology is about as effective as in-person psychotherapy. However, some therapists believe that something is lost by not being in the same room. For example, there is debate about a therapist’s ability to fully understand nonverbal information when working remotely. Electronic Communications We will be using the telecommunication service listed below. You will need a cell phone, tablet or computer with a camera and microphone to use telepsychology services. You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software to take part in telepsychology. Confidentiality I have a legal and ethical responsibility to make my best efforts to protect all communications that are a part of our telepsychology. Our system is HIPAA compliant and does not store session content. However, the nature of electronic communications technologies is such that I cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. You should also take reasonable steps to ensure the security of our communications (for example, having passwords to protect the device you use for telepsychology). Technical Concerns If the session is interrupted, disconnect from the session and I will wait two (2) minutes and then re-contact me via the telepsychology platform on which we agreed to conduct therapy. If you do not receive a call back within two (2) minutes, then I will contact you via phone. If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time. Fees The same fee rates will apply for telepsychology as apply for in-person psychotherapy. However, insurance or other managed care providers may not cover sessions that are conducted via telecommunication. If your insurance, HMO, third-party payor, or other managed care provider does not cover electronic psychotherapy sessions, you will be solely responsible for the entire fee of the session. Please contact your insurance company prior to our engaging in telepsychology sessions in order to determine whether these sessions will be covered. Records The telepsychology sessions shall not be recorded in any way. I will maintain a record of our session in the same way I maintain records of in-person sessions in accordance with my policies. Informed Consent This agreement is intended as a supplement to the general informed consent that we agreed to at the outset of our clinical work together and does not amend any of the terms of that agreement. Your signature below indicates agreement with its terms and conditions Date* MM slash DD slash YYYY Typing your name in the box below is your electronic signature on this document.Client Name* Therapist* Telecommunication Method* Audio-visual platform Telephone Multiple methods Provider's Name*
