INFORMED CONSENT FOR TELEPSYCHOLOGY
William C. Sanderson, PhD
Psychotherapy delivered via telephone or internet
This Informed Consent for Telepsychology contains important information focusing on doing psychotherapy using the telephone or 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. 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 if the client or clinician moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It also provides an opportunity for treatment that may not be available in your locale. 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 the therapist’s 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 and always be in a private location (my office or home office). 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 computer 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. I will not engage in telepsychology with clients who are currently in a crisis requiring high levels of support and intervention. If a crisis arises in treatment, I will make efforts to provide assistance but I can not provide routine emergency services. I may ask you to identify an emergency contact person who is near your location and who I can contact in the event of a crisis or emergency to assist in addressing the situation. You will need to identify emergency services and other resources in your area to address any need for crisis or emergencies.
- Efficacy. Most research shows that telepsychology is not significantly different in effectiveness from 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.
Electronic Communications We will decide together which kind of telepsychology service to use based upon your preference and convenience.
Please be reminded that for communication between sessions, I only use email communication and text messaging with your permission and only for administrative purposes unless we have made another agreement. You should be aware that I cannot guarantee the confidentiality of any information communicated by email or text. Therefore, please refrain from discussing any clinical information by email or text. This should be limited to practical matters such as changing appointments. Also, I do not respond to correspondence immediately and thus 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, local mental health crisis service or the nearest emergency room and ask for the mental health professional on call.
Confidentiality I have a legal and ethical responsibility to make my best efforts to protect all communications that are a part of our telepsychology. 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.
The extent of confidentiality and the exceptions to confidentiality that I outlined in my consent to treatment that you signed at your initial appointment still apply in telepsychology. Please let me know if you have any questions about exceptions to confidentiality (I have provided that information below in the event you would like to review it again).
If the session is interrupted (e.g., the call or connection is lost), disconnect from the session and I will wait one minute and then re-contact you via the telepsychology platform on which we agreed to conduct therapy. Please note that 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.
If you Submit Receipts to Insurance: Psychologists have been advised that insurance will cover telepsychology. Please note that I must now add a "modifier" to the CPT Code on receipts for this service. The code now will become: - 90834 - modifier 95 - in case you want to check with your insurance in advance. The modifier indicates it was a remote but synchronous session (meaning it occurred in real time).
Records The telepsychology sessions shall not be recorded in any way by either of us. This would represent a clear violation of privacy rules. I will maintain a written record of our session in the same way I maintain records of in-person sessions in accordance with my policies.
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 (see below for a reminder - if you would like to make any changes on the original privacy forms please let me know).
Your signature below and returning this form to me in person or by mail, or replying to this email stating that "I agree with this document" indicates agreement with its terms and conditions.
*****Signature: _____________ _______________________ Printed Name: Date: _______________________
*****Signature: _____________ _______________________ Printed Name: Date: _______________________
I authorize Dr. William C. Sanderson to contact me via the following methods (circle all that apply). Typically, contact initiated by Dr. Sanderson will be to confirm or reschedule an appointment or to provide you with information that you have requested.
Yes No Mail to my home address
Yes No Telephone (including leaving a voicemail message)
Yes No Email (to an email address that I provide)
Yes No Text message
*****Signature: _____________ _______________________ Printed Name: Date: _______________________
Because email is not a secure form of communication guidelines have been created by the federal government. As you probably know, although unlikely, there is a possibility that information included in an email can be intercepted and read by other parties. Thus, if you choose to correspond with me by email, I must inform you that I use gmail, which is considered an "unsecure" email (that is, non-encrypted). If you prefer that I do not communicate with you by email, just let me know at any time, and I will honor your request. If you decide to communicate by email, please note that the following types of messages are appropriate: (1) appointment scheduling, (2) non-urgent advice/discussion/correspondence.
Please do not email about urgent problems or emergencies. If you need immediate assistance call my telephone number (516-690-7278) for instructions.
I understand that the confidentiality of communication through e-mail exchanges cannot be guaranteed. I understand that if my therapist is obtaining information only via e-mail, s/he is making clinical judgments on the basis of limited and imperfect information. I understand that my therapist may not receive e-mail in a timely fashion and that if my communication is urgent it is best to use the telephone to call 911. I understand that if I choose to correspond with my therapist through e-mail, s/he will make every effort to keep the information s/ he receives confidential, but that s/he cannot guarantee confidentiality of e-mail communications. If I communicate with my therapist via e-mail, I agree to accept the risk that a breach of confidentiality may occur.
*****Signature: _____________ _______________________ Printed Name: Date: _______________________
CONSENT FOR PSYCHOLOGICAL SERVICES
I agree to undergo psychological evaluation and/or treatment with Dr. William Sanderson. Dr. Sanderson is a licensed clinical psychologist in the state of NY and is committed to providing caring, timely, professional treatment to the best of his ability. I agree to participate fully in the evaluation or treatment and I understand that I will be given feedback from my doctor regarding his or her assessment of my functioning and/ or progress. I understand that my participation in this assessment and treatment is entirely voluntary and that I may discontinue the assessment or treatment at any time. If I wish to withdraw from the assessment/ treatment, I can discuss other options with Dr. Sanderson.
I understand that it is my responsibility and Dr. Sanderson’s recommendation that I get a thorough physical examination from an internist to rule out any undiagnosed medical diseases. I understand that my doctor practices psychotherapy and does not prescribe medication. I understand that he is willing to refer me to a psychiatrist for a medication evaluation should I request it.
I understand that what I say in sessions or over the telephone is confidential information and will not be communicated to anyone, including family members, without my written consent. There are, however, three important exceptions to this guideline. The first exception is when there is clear and immediate danger to myself. The second exception is when there is clear and immediate danger to others. With regard to the second exception, the law requires the professional to report past child or elderly abuse even though it is not presently occurring. The third exception is when ordered by a court of law. In all of these cases, I understand that my doctor is legally required to report to the appropriate individuals or agencies. (Please read the HIPPA Statement and Notification of Privacy Practices below for more details about privacy of information).
I understand that I am responsible to pay the fee quoted by Dr. Sanderson for the service provided. Dr. Sanderson is not an insurance provider and not a Medicare provider. If I have Medicare I understand I will notify Dr. Sanderson right away so that he can complete required paperwork.
I understand that a portion of the fee may be covered by medical insurance plans and that I will be given a receipt suitable for billing the insurance company on my own. I agree to take responsibility for reviewing the coverage of my insurance policy.
I understand that 24 hours advance notice must be given to cancel a scheduled session, or I will be billed the full amount for that session.
I understand that my doctor is usually not reachable in an emergency -- whether it be by telephone, email, or text -- and thus, in a situation where I require immediate care I agree to go to my local hospital emergency room or call 911.
I understand that I have the opportunity to ask questions about this document before signing it. I will receive a copy of this document for my records.
*****Signature: _____________ _______________________ Printed Name: Date: _______________________