Intake Forms

Telehealth                                                        

INFORMED CONSENT CHECKLIST FOR TELEPSYCHOLOGICAL SERVICES

Prior to starting video-conferencing services, we discussed and agreed to the following:

• There are potential benefits and risks of video-conferencing that differ from in-person sessions. You should check with your cell phone carrier regarding confidentiality.

• Confidentiality still applies for telepsychology services, and nobody will record the session without the permission from the others person(s).

• We agree to use the video-conferencing platform selected for our virtual sessions. We use Simple Practice.

• You need to use a webcam on your computer or smartphone during the session.

• It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.

• It is important to use a secure internet connection rather than public/free Wi-Fi.

• It is important to be on time. If you need to cancel or change your tele-appointment, you must notify the psychologist in advance by phone or email.

• We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.

• We need a safety plan that includes at least one emergency contact and the closest ER to your location, in the event of a crisis situation.

• If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in telepsychology sessions.

• You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment.

• As your psychologist, I may determine that due to certain circumstances, telepsychology is no longer appropriate and that we should resume our sessions in-person.