Informed Consent for Telepsychological Services
Record #
Informed Consent for Telepsychological Services
Prior to starting telepsychological services from Angel Enrique Pacheco, Ph.D., C.Psych., his Assistants, and/or Associates in the form of telephone or video-conferencing services, we discussed and agreed to the following:
- There are potential benefits and risks of telephone or video-conferencing (e.g., limits to confidentiality) that differ from in-person sessions.
- With the exception of mandatory limits, confidentiality still applies for telepsychology services, and nobody will record the session without the permission from the other person(s).
- For video sessions, we agree to use the video-conferencing platform selected by the psychologist for our virtual sessions, and the psychologist will explain how to use it.
- You need to use a webcam or smartphone during the session. Ensure you have adequate battery power, if required. Preferably, plug-in your device to an electrical outlet during the session.
- It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.
- For video sessions, it is important to use a secure internet connection rather than public/free Wi-Fi.
- It is important to be on time. If you need to cancel or change your tele-appointment, you must notify the psychologist at least twenty-four (24) hours in advance, excluding weekends and statutory holidays; otherwise, regular consultation charges apply. The fees for telepsychological services are the same as for in-person sessions, as per the applicable Cost Sheet for our professional services.
- We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.
- We need a safety plan that includes at least one emergency contact and the closest Hospital Emergency Room to your location, in the event of a crisis situation.
- If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in telepsychology sessions.
- You should confirm with your insurance company that the telephone or video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment.
- As your psychologist, I may determine that due to certain circumstances, telepsychology is no longer appropriate and that we should resume our sessions in-person.
IMPORTANT NOTICES:
If required, call Dr. Pacheco, his Assistants, and/or Associates and, if not available immediately, please leave a voice mail message with your name, telephone number, and a brief description of the situation. Your call will be answered as soon as possible.
In the event of an emergency, call 911, or go to the nearest Hospital Emergency Room, where you will be assisted.
By signing this form, I confirm that:
- I have had the opportunity to ask any questions about the preceding information;
- I consent to telepsychological services in the form of telephone or video-conferencing services from Dr. Pacheco, his Assistants, and/or Associates;
- I consent to the use of e-mail and/or text messages;
- I consent to the use of e-mail and/or text messages for matters relating to scheduling, changing, and/or cancelling appointments, as well as for receiving Professional Services Statements and matters thereof;
- I will follow the guidelines listed above;
- I agree to accept, as outlined above, e-mail and/or text messages from Dr. Pacheco, his Assistants, and/or Associates;
- I accept full responsibility for such communications;
- I acknowledge receipt of a copy of this document, of the Cost Sheet, Privacy and Confidentiality Policy Summary, and of the Privacy Policy.
ACCEPTED IN ACCORDANCE:
Printed Name Signature Date
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