Telepsychology Informed Consent
(Telepsychology is also called telehealth, telemental health, telebehavioral health, and telemedicine among other terms.)
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Name *
Date of Birth *
Information about telehealth
Some expected benefits of telepsychology: greater access to services, more convenience when accessing services, and less exposure to contagions.
Some possible risks of telepsychology: reduced information available for accurate assessment and treatment when compared with in-person psychology, delays in assessment or treatment due to technical difficulties, interception of or unauthorized access of health care information, and limitations on the psychologist's ability to respond to emergency situations.
The same rules of confidentiality apply for telepsychology services as in-person services.
Sometimes telepsychology is not appropriate for the care you need. In that case, we should make other arrangements such as meeting in person or finding a referral that better suits your needs.
In cases of emergency, the psychologist may send police, emergency medical personal, or others if needed to your location.
What you need:
You must be physically located in a place where your provider is licensed to practice. Dr. White is licensed in Minnesota, so you MUST BE IN MINNESOTA during your therapy session unless other arrangements have been made.
Make sure you are in a safe and private location with good network access.
You will need a device with a camera and microphone such as a smartphone or computer. You may be asked to grant access to your camera and microphone.
You will need a web browser to access the telepsychology web site.
A private internet connection is more secure than a public or free Wi-Fi connection. Use the level of security that suits your level of acceptable risk.
You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment.
Plans for Safety *
In a medical or mental health emergency (check all that apply):
By signing here, I agree to use the resources marked here as needed for my own safety before, during, or after a telepsychology session. *
(Sign by typing your name.)
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