TelePsychology Consent Form Youth

TelePsychology involves the communication of your medical/mental heath information, both orally and/or visually. All sessions are scheduled in a consistent manner with in-person sessions, through our administrative staff. Video calls received during non-appointment times will not be answered or returned.

TelePsychology has the same purpose or intention as psychotherapy or therapy treatment sessions that are conducted in person. However, due to the nature of the technology used, it is important that you understand that TelePsychology may be experienced somewhat differently than face-to-face treatment sessions.

Fees:

Session fees are typically collected in-person using a variety of payment methods. As off-site services eliminate this possibility you will be asked to provide your credit card information (Visa or MasterCard only) prior to your session or at the time of booking to ensure this information is available for billing at session completion. Failure to provide this information may result in your session being delayed or cancelled. Fees for TelePsychology services are consistent with in-person fees (i.e. $225.00 per 50-minute session). Upon payment, you will receive an electronic receipt that may be submitted for insurance purposes.

Consent:

Consent to services will be obtained through verbal means, since the provider and client are not in the same physical location to obtain written consent. That is, you are providing consent to services by participating in the TelePsychology meeting and will be asked to “verbally consent to services” in lieu of physically signing a document in person. Should you attend a face-to-face meeting in the future, you may be asked to sign a document providing written consent for TelePsychology. Marsh-Knickle & Associates general “Informed Consent Form” can be found on our website at mkpsych.com (under the “Forms & Links” tab/page).

Technology Issues, Missed Appointments, Insufficient Cancellation, or Rescheduling Notice:

The policy regarding missed appointments, insufficient cancellation, and rescheduling notice is the same as that outline in our practice’s general “Informed Consent Form” found on our website. Given that technological issues can arise with TelePsychology, it is important that you and your treatment provider discuss what will happen in the event of a technological failure or disruption in service. Options include calling your clinical directly at the number they provided to you. Please note that session fees will apply in full if the service interruption is due to technology failures or other issues encountered outside of our office (poor internet connection, computer failure due to low battery, etc.)

Client’s Rights, Risks, and Responsibilities

I understand that I have the following rights and responsibilities with respect to TelePsychology:

1. My child needs to be a resident of Nova Scotia and physically present in Nova Scotia at the time of service delivery, unless the psychologist they are seeing has been granted permission to see them in the province/state they are located in.
2. I understand that, in accordance with Model Standards for TelePsychology Service Delivery (ACPRO June 2011), I may be asked to provide some form of verifiable identification to minimize the possibility of impersonating a parent/client and gaining access to confidential health information.
3. I, the parent of the client, have the right to withhold or withdraw consent at any time without affecting my child’s right to future care or treatment.
4. The laws that protect the confidentiality of my child’s medical information also apply to TelePsychology. As such, I understand that the information disclosed by me/my child during the course of my child’s therapy or consultation is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, which are described in the general “Informed Consent Form” that can be found on our website at mkpsych.com (under the “Forms and Links” tab/page).
5. I understand that there are risks and consequence of participating in TelePsychology, including but not limited to, the possibility, despite best efforts to ensure high encryption and secure technology on the part of my clinician, that: the transmission of my child’s information could be disrupted or distorted by technical failures; the transmission of my child’s information could be interrupted by unauthorized persons; and/or the electronic storage of my child’s medical information could be accessed by unauthorized persons. Potential threats include, but not limited to, computer viruses, hackers, theft of technology devices, damage to hard drives or portable drives, failure of security systems, flawed software, ease of accessibility to unsecured electronic files, or outdated technology. Other threats may include policies and practices of technology companies and vendors (Guidelines for the Practice of TelePsychology, APA 2013).
6. In addition, I understand that TelePsychology based services and care may not be as complete as face-to-face services. I also understand that if my clinician believes my child would be better served by another form of therapeutic services, he/she will be referred to a professional who can provide such services in my geographical area.
7. I understand that my child may benefit from TelePsychology, but that results cannot be guaranteed or assured. I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my clinician, my child’s condition may not improve, and in some cases may even get worse.
8. I understand that there is a risk of being overheard by anyone near me if I am not in a private room while participating in TelePsychology. I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my TelePsychology sessions and (2) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my TelePsychology session. It is the responsibility of the therapy treatment provider to do the same on their end.
9. I accept that TelePsychology does not provide emergency services. If my child is experiencing an emergency situation, I understand that I can call 911 or proceed to the nearest hospital emergency room for help. I can also contact the Mental Health Mobile Crisis Team 24/7 if I am experiencing a mental health crisis at 1-888-429-8167. Clients who are actively at risk of harm to self or others are not suitable for TelePsychology services. If this is the case or becomes the case in the future, my clinician will recommend more appropriate services.
10. I understand that dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my written consent.
11. Sessions will not be recorded by my treatment provider and I will refrain from taping, recording, or sharing/streaming sessions without first obtaining clear consent from my treatment provider.

Disclaimer: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

I have read, understand and agree to the information provided above regarding telehealth: