Michael Feeley, PhD

Licensed Psychologist -- Caring and Compassionate Help with Life Goals and Problems.

Appointments during the coronavirus pandemic use video and phone calls.

If you have any questions, please call me at 1-888-933-3539.

Stay safe.

You are here: Home -> Intake Forms and My Schedule -> Informed Consent for Telepsychological Services

Informed Consent For Telepsychological Services

This Informed Consent for Telepsychology contains important information focusing on doing psychotherapy using the telephone or the Internet. Please read this carefully, and let me know if you have any questions.

When you sign this document, it will represent an agreement between us.

Benefits and Risks of Telepsychology

Telepsychology refers to providing psychotherapy services remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of telepsychology is that the client and clinician can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care of the client or clinician moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It is also more convenient and takes less time.

Telepsychology, however, requires technical competence on both our parts to be helpful. Although there are benefits of telepsychology, there are some differences between in-person psychotherapy and telepsychology, as well as some risks. For example:

Electronic Communications

We will decide together which kind of telepsychology service to use. You may have to have certain computer or cell phone systems to use telepsychology services. You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software to take part in telepsychology.

For communication between sessions, I only use email and telephone communication, with your permission, and only for administrative purposes. This means that email exchanges and telephone calls with my office should be limited to administrative matters. This includes things like setting and changing appointments, billing matters, and other related issues.

You should be aware that I cannot guarantee the confidentiality of any information communicated by email or telephone. Therefore, I will not discuss any clinical information by (un-encrypted) email or telephone call and prefer that you do not either. I do ask clients to get a free email account from an encrypted email provider: Protonmail.com. Protonmail email is encrypted by default between Protonmail accounts. I have a business account with them which is HIPAA-compliant. Also, I do not regularly check my email or voicemail, nor do I respond immediately, so these methods should not be used if there is an emergency.

Treatment is most effective when clinical discussions occur at your regularly scheduled sessions. But if an urgent issue arises, you should feel free to attempt to reach me by phone. I will try to return your call within 24 hours except on weekends and holidays. If you are unable to reach me and feel that you cannot wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact in my absence if necessary.

Confidentiality

I have a legal and ethical responsibility to make my best efforts to protect all communications that are a part of our telepsychology sessions. However, the nature of electronic communications technologies is such that I cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. I will try to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for telepsychology sessions and having passwords to protect the device you use for telepsychology).

The extent of confidentiality and the exceptions to confidentiality that I outlined in my Informed Consent still apply in telepsychology. Please let me know if you have any questions about exceptions to confidentiality.

Appropriatenessof Telepsychology

From time to time, we may schedule in-person sessions to “check-in” with one another. I will let you know if I decide that telepsychology is no longer the most appropriate form of treatment for you. We will discuss options of engaging in in-person counseling or referrals to another professional in your location who can provide appropriate services.

Emergencies and Technology

Assessing and evaluating threats and other emergencies can be more difficult when conducting telepsychology than in traditional in-person therapy. To address some of these difficulties, we will create an emergency plan before engaging in telepsychology services. I will ask you to identify an emergency contact person who is near your location and who I will contact in the event of a crisis or emergency to assist in addressing the situation. I will ask that you sign a separate authorization form allowing me to contact your emergency contact person as needed during such a crisis or emergency.

If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call me back; instead, call 911, or go to your nearest emergency room. Call me back after you have called or obtained emergency services. If the session is interrupted and you are not having an emergency, disconnect from the session and I will wait two (2) minutes and then re-connect with you via https://doxy.me/drmichaelfeeley or my business telephone (888-933-3539). If we do not reconnect via video session or you do not receive a call back within two (2) minutes, then call me on the phone number I provided you (888-933-3539).

If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time.

Fees

The same fee rates will apply for telepsychology as apply for in-person psychotherapy. However, insurance or other managed care providers may not cover sessions that are conducted via telecommunication. If your insurance, HMO, third-party payor, or other managed care provider does not cover electronic psychotherapy sessions, you will be solely responsible for the entire fee of the session. Please contact your insurance company prior to our engaging in telepsychology sessions in order to determine whether these sessions will be covered. If you are paying for sessions yourself, you will need to mail a check to me.

Records

The telepsychology sessions shall not be recorded in any way unless agreed to in writing by mutual consent. I will maintain a record of our session in the same way I maintain records of in-person sessions in accordance with my policies.

Physical Location of Client

In Pennsylvania, a licensed psychologist may only conduct sessions with people who are physically located in Pennsylvania. I also need to be relatively close to my clients' homes for emergencies. Because of this, I am limiting my telepsychology practice to the same areas as my in-session practice: Bucks, Chester, Delaware, Montgomery and Philadelphia counties. You must live in one of those counties in order for us to have telepsychology sessions.

Informed Consent

This agreement is intended as a supplement to the general informed consent that we agreed to at the outset of our clinical work together and does not amend any of the terms of that agreement. Your signature at the bottom of this document indicates agreement with its terms and conditions.

In Summary

In summary, we discussed and agreed to the following:

Patient/Client Name:

Patient/Client Signature (handwritten or electronic):

Psychologist Name: Michael Feeley, PhD

Psychologist Signature (handwritten or electronic):

Date:

If you have any questions or would like to schedule an appointment, please call: 888-933-3539.

I’d be happy to speak with you.

Mike Feeley