Consent to Psychotherapy by Audio and/or Audio+Video Service (“Telehealth”)
INSTRUCTIONS: THIS FORM IS MEANT TO BE PRINTED OUT AND FILLED OUT TO BE RETURNED TO DR.SEGEL. Please do not try to complete this form online - there is no guarantee of privacy, nor that it will reach Dr. Segel.
In light of the Covid-19 epidemic, Dr. Beth Segel is offering telehealth services to current clients. This is a temporary and emergency-driven measure intended to prevent the spread of this devastating illness. In general, the research comparing telehealth to in-person psychotherapy is limited, but suggests they may produce comparable results. Individual psychologists, such as Dr. Segel, believe that they can be most effective in person – and hope to return to it as soon as it is safe and practical. In the meantime, the following options are offered.
Telehealth services, while bridging the gap during this time, create other concerns. These can include
) interruption of service due to technical problems,
2) personal information being accessed, and potentially misused by unknown third parties during the transfer of intimation via phone or Internet services, and
3) information being overhead by third parties near either the psychologist or client.
Both Dr. Segel and the client signing below agree to be proactive to take the steps necessary to prevent these problems.
Dr. Segel agrees to do her best to:
1) choose a service provider who will agree to provide appropriate levels of privacy and service continuity,
2) continue to educate herself on issues relevant to treatment in this mode, and
3) maintain privacy of the information received in the interactions, including holding the sessions in a private room with a closed door, free of interruptions, and where no client information can be overheard. This includes no recording of the session.
I _________________________________ (print name here) agree to have my psychotherapy temporarily provided by
□ Audio only (telephone)
□ Audio + video
□ Either option above
as long as the Covid-19 epidemic makes it unsafe or unwise for Dr. Beth Segel to meet with me in person. I also agree 1) not to hold the session in a place where we can be overheard or interrupted, 2) not to record the session, and 3) to use the communication method that is most private for me.
The extent of confidentiality and the exceptions to confidentiality that are outlined in the Informed Consent form (at first appointment) still apply in telepsychology. Dr. Segel agrees to be available to answer any questions that I may have about exceptions to confidentiality.
Emergencies and Interruptions
If the session is interrupted for any reason, such as the technological connection fails, and I am having an emergency, I will not call Dr. Segel back; instead, I will call 911, a hotline, or go to the nearest emergency room. Then I can call the psychologist back after I have called or obtained emergency services.
If the session is interrupted and I am not having an emergency, I will disconnect from the session and I will wait two (2) minutes for Dr. Segel to re-contact me via the telepsychology platform on which we agreed to conduct therapy. If I do not receive a call back within two (2) minutes, then I can call Dr. Segel at a number that Dr. Segel will provide after we complete this agreement.
If there is a technological failure and we are unable to resume the connection on video, Dr. Segel will finish the session over regular telephone contact, if at all possible.
Fees
The same fee rates will apply for telepsychology as apply for in-person psychotherapy, unless my insurance company has waived my copay for the Covid-19 crisis. I am responsible to ensure that I pay Dr. Segel any copay due in a timely way.
However, insurance or other managed care providers may not cover sessions that are conducted via telecommunication. Dr. Segel has temporarily assumed responsibility for ensuring that she will be paid by insurance companies for sessions through 4/27/2020. However, it is now my responsibility to contact my insurance company prior to continuing telepsychology sessions in order to determine whether these sessions will be covered. I agree to contact my insurance company and report the results to Dr. Segel in the next 2 days, so that we can determine how the sessions will be financed.
Records
The telepsychology sessions shall not be recorded in any way unless agreed to in writing by our mutual consent. Dr. Segel will maintain a record of our session in the same way she makes notes of in-person sessions in accordance her standard practices.
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.
I am free to review and/or work out mutually-agreed changes to this agreement at any time, with one week advance notice to Dr. Segel. (Lead time allows Dr. Segel to adjust the service to ensure that I receive the best quality care.)
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Client Signature Date