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INFORMED CONSENT FOR TELEPSYCHOLOGY SERVICES
Prior to starting video-conferencing services, I am aware of and agreed to the following:
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Name of client:
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Name of person completing this form:
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Person completing this form relationship to client:
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Please check all of the following to indicate your agreement and understanding:
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There are potential benefits and risks of video-conferencing (e.g., privacy considerations) that differ from in-person sessions.
You will need to find a quiet, private space that is free of distractions during the session.
Confidentiality still applies for telepsychology services, and neither you nor Dr. Spader-Cloud will record the session.
You agree to use the video-conferencing platform selected for our virtual sessions (
www.doxy.me
), and Dr. Spader-Cloud will explain how to use it.
You will need to use a webcam or smartphone during the session.
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 Dr. Spader-Cloud in advance by phone or email (48 hours’ notice is requested to avoid a $50 reschedule fee).
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. (This is Not Applicable for those not using insurance for services with Dr. Spader-Cloud).
As your psychologist, Dr. Spader-Cloud may determine that due to certain circumstances, telepsychology is no longer appropriate and that we should resume our sessions in-person.
We need a back-up plan to restart the session or to reschedule it, in the event of technical problems. Dr. Spader-Cloud will typically try to call your cell phone. Please enter this information below.
We need a safety plan that includes at least one emergency contact and the closest Emergency Room to your location, in the event of a crisis situation. Please enter this information below.
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Please provide a phone number at which Dr. Spader-Cloud can call you in the event of technical problems:
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Please list your emergency contact person's name and phone number:
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Please list the name of your closest Emergency Room:
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Signature of Patient or Parent/Legal Guardian (by typing your name below, you indicate your agreement to the information contained within this Informed Consent for Telepsychology Services.
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