Prior to starting phone or video-conferencing services, we discussed and agreed to the following: 

There are potential benefits and risks of telephone or 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 others person(s). 

● We agree to use the video-conferencing platform or other compliant platform for 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. 

●I may determine that due to certain circumstances, telepsychology is no longer appropriate and that we should resume our sessions in-person. 

Client Name: ___________________________

Signature of Client:_____________________ 


Telephone Number: ___________________________