Psychologist Telehealth Informed Consent-Evaluation

Mark D. Ackerman, Ph.D. Licensed Psychologist

2751 Buford Highway Suite #410 Atlanta, GA 30324

Telephone: 770-396-2206
E-Mail Address: DrMark@clinicalforensicpsychsvs.com
Website: ClinicalForensicPsychSvs.com

Psychologist Telehealth Informed Consent-Evaluation

Thank you for scheduling a telehealth (e.g. virtual) evaluation appointment. Telehealth sessions are conducted in a video-conferencing format and require you to have computer access so that we can see and hear each other. Telehealth evaluation sessions are convenient and reduce the need for travel to my office. They also help by providing me with the background information that I may need to provide you with a recommendation for the next phase of your evaluation, e.g. in-office or remote testing, etc. You have the choice to discontinue at any time and request an in-office evaluation. By signing this agreement, you acknowledge that you have been advised that telehealth sessions are at your request. Data Security: To safeguard your privacy, my practice uses a secure, HIPPA-compliant platform for all telehealth services. Evaluation session notes are kept on paper form and are not stored on computers, cloud-based systems, or other electronic media. Legal Issues: The confidentiality of all communications between patient/client and psychologist is protected by law. In most cases I can only release information about our work to yourself or others with your written permission. However, exceptions to this include dangerousness to self and others, child/elder abuse or suspicion of child/elder abuse, and certain court proceedings. Should such a situation occur, I may be legally obligated to break confidentiality.

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Please note that if I am ever required to attend a deposition or if I am issued a subpoena or asked to testify in court concerning my work with you, you agree to pay my hourly court appearance fees for preparation and testimony in advance of my deposition and/or court appearance.

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All telehealth evaluation sessions will remain fully confidential unless ordered by a court or other legal entity. Your records will be maintained in a locked file and will be given the same confidential treatment as applies to in-office evaluation sessions. All the current standards of psychological practice including professionalism, confidentiality and “duty to warn” for safety concerning yourself or someone else will apply. You are encouraged to contact this office if you have questions concerning telehealth evaluation sessions or this agreement.

Kindly complete the requested information, and sign and date below your agreement to go forward with the terms of this agreement.

Your Name

Date of Birth

Email address

Telephone Number that you wish to be contacted at

Residence Address

Fees: The fee for the initial 50-minute telehealth evaluation session is $350.00* and includes discussion of the presenting concern, brief assessment as indicated, guidance and treatment planning if requested but does not include a written report. Initial telehealth evaluation sessions may recommend follow-up for further and more comprehensive diagnostic evaluation which may include document review, objective psychological testing to assist with diagnosis or a written report at your request that may be used for a personal, legal, military enlistment, diagnostic clarification, treatment planning or employment matter. If you request a written report a fee based on time needed to complete the report is required.

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Expiration Date

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Cancellations: We understand that situations arise unexpectedly resulting in a need to change or cancel an appointment. To be fair to us, we ask that you provide notice to our practice via e-mail message or telephone call at least 48 hours in advance of your need to change or cancel your appointment. **

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Date

*All credit/debit card charges include an additional .0395% processing fee

** A “no show” charge equaling the cost of one session will be incurred if you do not contact our practice in advance to notify us that you need to change or cancel your scheduled appointment.

I have read and understand the information provided above and am aware that I may ask for additional information. I hereby consent to telehealth services as a part of my evaluation and/or treatment plan.

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My practice looks forward to assisting you.

Sincerely,

Michelle, Office Manager for:
Mark D. Ackerman, Ph.D.
Licensed Psychologist

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