Turning Point Psychotherapy Associates, LLC Telehealth Form

This document pertains to the provision of Telehealth Psychotherapy Sessions for our patients.

Please correct the errors described below.

Telehealth Guidelines

Telehealth psychotherapy sessions will take place either via phone or interactive video using your computer, smart phone or tablet device. This section sets forth the guidelines for Telehealth psychotherapy and provides useful information about conducting sessions via phone or video. SESSION STRUCTURE It is important to maintain a setting that is as similar to being in the office together as possible. In order to have effective telehealth psychotherapy, please observe the following guidelines: (1) Make sure that you are in a private location where your session cannot be overheard by others. Make sure to adjust the volume on your device to ensure your privacy. You are required to inform your therapist if there is anyone in the room with you, or who you believe may overhear session. (2) Minimize background noise and distractions. Turn off tv’s, music or other sounds. (3) In a video session, place your device on a steady surface throughout session. Do not hold in your hand if it can be avoided. If it must be in your hand, please hold it as steady as possible. Please try to be in a set location and not moving around. Try to have proper lighting so that the therapist can best communicate with you. (4) If the connection is broken for any reason, your therapist will call you to try to remedy the situation. (5) You may not invite others into session time without discussing this with your therapist first. (6) Video and/or audio recording of sessions and taking pictures/screenshots is strictly prohibited. VIDEO PROCEDURES AND TECHNICAL ISSUES A video session reminder email will be sent to you before the start of your session. This email will provide a link to your video session. Scroll down the text of your email to the phrase "Join Video Session". Click on this to log in to the session. It is advised that you log in 5-10 minutes in advance of your session start time so as to be sure the the link works and to engage in any troubleshooting if issues arise before session. If you to not receive an email with the link to your video session at least 10 minutes before the start of the session, please contact your therapist to let her know so that she might resend the link. If you plan to use your smartphone or other handheld device for the session, you will need to download the app "Telehealth by SimplePractice" before the start of the appointment. To participate in the session, simply click on the "Join Video Session" link within your email and it will automatically divert you to the app to begin. If you are using your computer, no additional steps are needed. It is certainly possible, during the course of a video session, that there could be problems that arise in connectivity from either party that may impact video or audio quality. Some of these problems could be related to wifi, internet connections or location. In the event of a disruption in transmission, your therapist will make every effort to reach you by phone to try to resolve the problem. If the video call cannot proceed, the remainder of the session will be completed via phone. EMERGENCIES If you are having a medical or psychological emergency, please dial 911 or go to your nearest emergency room. In addition, the following resources may be useful to you in a crisis situation: Valley Creek Crisis 610-280-3270 National Suicide Prevention Lifeline 1-800-273-8255 1-800-SUICIDE
 TELEHEALTH RIGHTS I understand that I have the following rights with respect to Telethealth psychotherapy: (1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. (2) The laws that protect the confidentiality of my medical information also apply to Telehealth. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. (3) I understand that there are risks and consequences from Telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychotherapist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons. In addition, I understand that Telehealth based psychotherapy services and care may not be as complete as face-to-face psychotherapy services. (4) I understand that I may benefit from Telehealth, but that results cannot be guaranteed or assured. PAYMENT Your standard fee, deductible, co-insurance or copay will be collected at the end of each session as usual. Payment will be processed via Ivy Pay and/or Simple Practice, which are both HIPAA secure, credit card payment systems. CANCELLATIONS A $75 fee will be charged for Telehealth psychotherapy sessions cancelled without 24 hours notice. Some exceptions will be made for serious illness or emergency.

Consent for Telehealth

I understand that my health care provider has offered to provide Telehealth psychotherapy. My health care provider explained to me how the phone or video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider. I understand that a Telehealth psychotherapy has potential benefits including easier access to care and the convenience of meeting from a location of my choosing. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the Telehealth psychotherapy session if it is felt that the phone or videoconferencing connections are not adequate for the situation. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand. CONSENT TO USE THE TELEHEALTH BY SIMPLEPRACTICE SERVICE Telehealth by SimplePractice is the technology service we will use to conduct Telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge: Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911. Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services. The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care. I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service. To maintain confidentiality, I will not share my Telehealth appointment link with anyone unauthorized to attend the appointment.

Signature

Please place a check next to all of the following statements to reflect that you are in agreement. Checking these boxes means that you are providing your consent to participate in Telehealth psychotherapy with Turning Point Psychotherapy Associates, LLC which includes the following therapists: Erin Jameson Saltzburg, MSSW, LCSW, Kathleen Young, MA, LPC, and Renae Utz, MSW, LCSW.

**EMAIL IS REQUIRED FOR ANYONE WISHING TO PARTICIPATE IN VIDEO SESSIONS**

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