Licensed Psychologist -- Caring and Compassionate Help with Problems and Goals.
A mask and a jab -- Do it for the Kids.
You are here: Home -> Intake Forms and My Schedule -> 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.
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:
Risks to confidentiality. Because telepsychology sessions take place outside of my private office, there is potential for other people to overhear sessions if you are not in a private place during the session. On my end I will take reasonable steps to ensure your privacy. But it is important for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation.
Issues related to technology. There are many ways that technology issues might impact telepsychology. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies.
Crisis management and intervention. Usually, I will not engage in telepsychology with clients who are currently in a crisis situation requiring high levels of support and intervention. Before engaging in telepsychology, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our telepsychology work.
Efficacy. Most research shows that telepsychology is about as effective as in-person psychotherapy. However, some therapists believe that something is lost by not being in the same room. For example, there is debate about a therapist’s ability to fully understand non-verbal information when working remotely.
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.
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.
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 for referrals to another professional in your location who can provide appropriate services.
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.
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.
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.
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: Chester, Delaware, and Montgomery counties. You must live in one of those counties in order for us to have telepsychology sessions.
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, we discussed and agreed to the following:
There are potential benefits and risks of video-conferencing (e.g., limits to patient confidentiality) that differ from in-person sessions.
Confidentiality still applies for telepsychology services, and nobody will record the session without the permission from the other person(s).
We agree to use the video-conferencing platform selected for our virtual sessions, and I will explain how to use it.
You need to use a webcam or smartphone 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.
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 me in advance by phone or email.
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 ER to your location, in the event of a crisis situation.
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.
You must live in certain, specific counties in Pennsylvania in order for us to
have telepsychology sessions (Chester, Delaware, and Montgomery counties).
As your psychologist, I may determine that due to certain circumstances, telepsychology is no longer appropriate and that we should find other options for you.
Client Electronic Signature
My electronic signature on this document indicates I have had all my questions answered, understand the contents of this document and agree to abide by it.