Informed Consent for Teletherapy and Online Therapy

Bucks County Anxiety Center

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Patient's Information

All therapists who practice at Bucks County Anxiety Center use this consent form for phone and virtual therapy sessions.

This Informed Consent for Teletherapy and Online Therapy contains important information on doing psychotherapy using the phone or the Internet. Please read this carefully and let me know if you have any questions.

This form is in addition to my standard intake paperwork. In addition to this form, you must also fill out the following forms:

  • Policy and Procedures
  • Intake
  • HIPAA Acknowledgement
  • Credit Card Authorization

All the policies and procedures in effect for in-person therapy apply to teletherapy sessions.

1) Benefits of Teletherapy

Teletherapy and virtual/online therapy refer to providing psychotherapy services remotely using telecommunications technologies, such as video conferencing or telephone.

Benefits of phone and virtual sessions include:

  • The patient and therapist can work together without being in the same physical location. This can be helpful in ensuring continuity of care if the patient or therapist moves, takes an extended vacation, or is otherwise unable to continue to meet in person.
  • Phone and virtual sessions are more convenient and takes less time.
  • Phone and virtual sessions can help people who have full schedules, childcare issues, limited transportation, or other conditions that prevent them from leaving the house.
  • There is also a lot of research showing that phone and virtual sessions can be just as effective as face-to-face therapy for many people.

2) Risks and Limits of Teletherapy

  • Risks to confidentiality: Since teletherapy 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. 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 an area where other people are not present and cannot overhear the conversation. Using headphones can also help protect your privacy.
  • Issues related to technology: Technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies.
  • Crisis management and intervention: Usually, I will not engage in teletherapy with clients who are currently in a crisis situation or require high levels of support and intervention. Before we work together via teletherapy, we will develop an emergency response plan to address potential crisis situations that may happen while we work together.

3) Efficacy

Most research shows that teletherapy is about as effective as in-person psychotherapy. However, some therapists believe that something is lost by not being in the same room.

Teletherapy is not effective for the following groups:

  • People who have a mental health or medical history, current situation, and/or specific need that is better addressed through in-person treatment.
  • Anyone who cannot have privacy during a session.
  • Teens and adults with developmental delays.
  • Anyone who feels uncomfortable using the phone or internet for therapy sessions.

4) Electronic Communications

We will decide together what kind of technology to use for our sessions. You may need certain computer or cell phone systems for teletherapy or online therapy. You are solely responsible for any cost to you to obtain necessary equipment, accessories, or software to take part in our sessions.

For communication between sessions, I only use email communication with your permission and only for administrative purposes unless we have made another agreement. As much as possible, please limit messages to administrative issues such as setting and changing appointments, billing matters, and other related issues.

Despite using HIPPA compliant services, I cannot guarantee the confidentiality of any information communicated by email or text. Therefore, I will not discuss any clinical information by email or text and prefer that you do not either. We can make other arrangements if we decide they are necessary.

5) Communication During Emergency Situations

DO NOT EMAIL OR TEXT DURING AN EMERGENCY. I do not regularly check my email or texts, nor do I respond immediately. These methods should not be used during an emergency.

If an urgent issue arises, you should feel free to attempt to reach me by phone. I will try to return your call within 24 hours except on weekends and holidays.

If you are unable to reach me and feel that you cannot wait for me to return your call, contact your county mobile crisis unit or go the nearest emergency room.

If I will be unavailable for an extended time, I will provide you with the name of a colleague providing coverage for my patients.

6) Confidentiality

I have a legal and ethical responsibility to try my best to protect all communications that are a part of our teletherapy. However, due to the nature of electronic technology, I cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications.

I will try to use updated encryption methods, firewalls, and back-up systems to help keep your information private. However, there is a risk that our electronic communications may be compromised, unsecured, or accessed by others.

You should also take reasonable steps to ensure the security of our communications (for example, only using secure Internet networks for teletherapy sessions and having passwords to protect the device you use for telepsychology).

The extent of confidentiality and the exceptions to confidentiality that are outlined in the Bucks County Anxiety Center Policy and Procedures document still apply in teletherapy. Please let me know if you have any questions about exceptions to confidentiality.

7) Appropriateness of Teletherapy and Online Therapy

During our first 2-3 sessions, I will assess whether teletherapy is a good fit for you and your needs. I will let you know as soon as possible if I believe this form of therapy is not a good fit for you. If it is not, we will discuss your options.

If we are already working together, I will let you know if I decide that teletherapy is no longer the most appropriate form of treatment for you due to changes in your situation or level of distress. We will discuss options of switching to in-person sessions or referrals to another professional in your location who can provide appropriate services.

8) Emergencies

Assessing and evaluating threats and other emergencies can be more difficult when conducting teletherapy than in traditional in-person therapy.

To address some of these difficulties, we will create an emergency plan before starting teletherapy.

In the last 2 pages of this form, I will ask you to do the following:

  • List the address you will most likely be in during our sessions.
  • Identify an emergency contact who is near your location and who I will contact in the event of a crisis or emergency to assist in addressing the situation.
  • Sign a separate authorization form allowing me to contact your emergency contact person as needed during a crisis or emergency. I will keep this only file and only use it during an emergency.
  • List contact information for your local police department and county crisis hotline.

If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call me back.

Instead call 911 or go to your nearest emergency room. Call me back after you have called or obtained emergency services.

9) Technology

If the session is interrupted and you are not having an emergency, hang up or end the video session. I will wait 1-2 minutes and then re-contact you via the teletherapy platform we were using.

If I cannot reach you, I will call you by phone. I may need to call from a different line. You may see the words Blocked Number, Unknown Caller, or Private on your caller ID. Please pick up to see if it is me.

I will try to contact you twice, either by video session or phone.

If you do not receive a call back within 2 minutes, call me on the Bucks County Anxiety Center main number (215-550-1818) and enter my extension.

If there is a technological failure that makes it impossible for both of us to resume the session either by video or phone, you will only be charged the prorated amount of actual session time.

If there is a technology failure because your phone battery died, you were in a poor signal area, or you were surrounded by people, you will be charged the full session fee.

If you are late for your session, we will speak for the time left. However, you will be charged for a full session.

10) Fees and Cancellations

The same fee rates apply for both teletherapy and in-person sessions.

You will be billed prior to your session. I can email you a receipt if you would like one.

Insurance or other managed care providers may not cover sessions that are conducted via phone or virtually. Please contact your insurance company as soon as possible to determine whether these sessions will be covered. You are solely responsible for the cost of phone and virtual sessions. I cannot alter the place of service to help you get reimbursed.

The same 24-hour cancellation policy applies to both teletherapy and in-person sessions.

If you cancel two out of three session with 24 hours’ notice, you will lose your standing appointment time. I will offer you sessions based on my availability. You will also have to pre-pay for sessions.

11) Records

Phone and virtual sessions shall not be recorded in any way. You may not take any screenshots of virtual sessions. Any kind of recording would violate this agreement and end our patient-therapist relationship. I will maintain a record of our sessions in the same way I maintain records of in person sessions in accordance with the ethics and laws of my state and license.

12) Informed Consent

This agreement is intended as an addition to the Intake Form, Policy and Procedures Form, HIPAA Acknowledgment Form, and Credit Card Authorization Form. This agreement does not amend any of the terms of those agreements

Your signature below indicates agreement with its terms and conditions.

In Pennsylvania, a minor who is 14 or older may seek out and receive outpatient psychotherapy without parental consent. There are situations in which the therapist will need to violate the minor’s confidentiality. For more information, please click here to read guidelines published by the ACLU.


Your Contact Information

Emergency Contact


If I determine you are in crisis or having an emergency, I will need to break confidentiality and reach out to your emergency contact person, your local police department, and/or 911.

If we are disconnected and you are having an emergency or are in crisis, DO NOT call me back. Immediately call 911 and stay on the phone with the operator until help arrives.

Release of Information Form

By signing this release, I give my therapist consent to speak with the person/care provider listed below regarding my case. This person is located 10-15 minutes away from where I am during out teletherapy sessions. I understand this person will be contacted if my therapist determines that I am in an emregency or crisis situation.

Your information will be encrypted.