John Roberts, Ph. D.
P.O. Box 1854
San Ramon, CA 94583
(925) 227-1122
Informed Consent for Telehealth Psychotherapy
This agreement is intended as a supplement to the Informed Consent for Psychotherapy and does not amend any of the terms of that agreement.
This Informed Consent for Telehealth Psychotherapy contains important information about the provision of psychotherapy services using a telephone. 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 Telehealth Psychotherapy
One of its benefits is that the client and clinician can engage in services without being in the same physical location.
Although there are benefits, there are some differences between in-person and telehealth therapy, as well as some risks. For example:
- Risks to confidentiality. Because psychotherapy sessions take place outside a therapist’s private office, it may be possible 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. It is important for you to make sure you find a private place for our session where you will not be interrupted or distracted. It is also important for you to protect the privacy of our session on your phone. 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 telephones. Our telephone connection may become disconnected or unuseable during a session. If this occurs, I will call you back as soon as possible to resume our session. If you don’t hear from me within a couple of minutes, please try calling me back.
- Crisis management and intervention. Usually, I will not engage in telehealth treatment with clients who are currently in a crisis situation requiring high levels of support and intervention. Before engaging in telehealth therapy, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our telehealth work.
- Efficacy. Most research shows that telehealth is about as effective as in-person psychotherapy. However, there may be some challenges that arise from not being in the same room. For example, non-verbal information may be difficult to fully discern.
For communication between sessions, I only use telephonic communication.
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. A list of crisis mental health resources is available on my website (www.JohnRobertsPhD.com).
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 telehealth therapy. However, the nature of electronic communications systems is such that I cannot guarantee that our work will be kept confidential or that other people may not gain access to it. Although I use a HIPAA-compliant, encrypted telephone line, there is a risk that our communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications.
The extent of confidentiality and the exceptions to confidentiality that I outlined in my Informed Consent for Psychotherapy Form are applicable to telehealth psychotherapy. Please let me know if you have any questions about exceptions to confidentiality.
Appropriateness of Telehealth
From time to time, we may check-in with one another to discuss how this is working. I will let you know if I determine that telehealth therapy is no longer an 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.
Fees
The same fee rates will apply for telehealth as apply for in-person psychotherapy. However, insurance or other managed care providers may not cover sessions that are conducted via telehealth. If your insurance, HMO, third-party payor, or other managed care provider does not cover telehealth psychotherapy sessions, you will be solely responsible for the entire fee of the session. Please contact your insurance company prior to our engaging in telehealth sessions in order to determine whether these sessions will be covered.
Records
The telehealth psychotherapy 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.
Emergencies and Technology
If you are having an emergency and the session is interrupted for any reason, such as the technological failure, do not call me back; instead, call 911, Alameda County Crisis Support Services (800 309-2131), Contra Costa County Crisis Center (800 833-2900), or go to your nearest emergency room. Call me back after you have called or obtained emergency services.
If you are not having an emergency and the session is interrupted, I will call you back as soon as possible. If a couple of minutes pass and you have not heard from me, please call me (925 227-1122).
If there is a technological failure and we are unable to re-establish the telephone connection, you will only be charged the prorated amount of actual session time.
Assessing and addressing threats and other emergencies can be more difficult when conducting telehealth than with traditional, in-person therapy. In the event of a crisis or emergency, I request that you to identify an emergency contact person(s) near your location to contact to assist in addressing the situation. I also will ask that you allow me to contact your emergency contact person as needed during such a crisis or emergency.
Emergency Contact
Contact #1 Name : _________________________________________________________________
Relationship : ____________________________________________________________
Phone Number : _________________________________________________________
Contact #2 Name : ________________________________________________________________
Relationship : _____________________________________________________________
Phone Number : ___________________________________________________________
With my signature below, I am authorizing Dr. Roberts to contact my emergency contacts in the event of a crisis or emergency to assist in addressing the situation. I am also agreeing with these terms and conditions and to engage in telehealth psychotherapy.
Client Signature & Date : __________________________________________________________
John Roberts, Ph.D. & Date : _______________________________________________________