2751 Buford Highway Suite #410 Atlanta, GA 30324
Thank you for scheduling a telehealth (e.g. virtual) treatment or consultation session. 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 appointments are convenient and reduce the need for travelling to our office. At times, access to a computer screen may not be available or desired, thus telephone sessions are also an option. You have the choice to discontinue at any time and request an in-office visit.
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 telehealth services. Therapy session notes are kept in paper form and are not stored on computers, cloud-based systems, or other electronic media. Legal Issues: The confidentiality of all communications between patient 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.
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.
All telehealth sessions will remain fully confidential and your records from each visit will be maintained in a locked file and will be given the same confidential treatment as applies to in-office treatment sessions. All the current standards of psychological practice including professionalism, confidentiality and “duty to warn” for safety concerning yourself or someone else will apply to your telehealth sessions. You are encouraged to contact this office if you have questions concerning telehealth treatment 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.
Fees: The fee for this 50-minute treatment or consultation appointment is $225.00* and can include spouse/partner, discussion of the presenting concern, consultation and/or treatment planning as requested.
Credit Card Information for Payment:
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. **
*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.
My practice looks forward to assisting you.
Sincerely,
Michelle, Office Manager for:Mark D. Ackerman, Ph.D.Licensed Psychologist
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