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Consent For Telepsychology Services 

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Definition of Services: Telepsychology services (also known as, Teletherapy) is a form of psychological service provided via secure internet technology. It has the same purpose or intention as psychological treatment sessions that are conducted face-to-face at the office of Marilyn Roberts. 

Due to the nature of the technology used, Telepsychology services may be experienced somewhat differently than face-to-face treatment sessions. Telepsychology involves arranging an appointment time with the client at their computer and the psychological service provider (therapist) interfacing from their computer via the internet.

Clients who are actively at risk of harm to self or others are not suitable for Telepsychology services. If this is the case, emergency services are recommended. If it becomes the case in a future session, more appropriate services will be provided or recommended.

Risks and Rights in Using Telepsychology:

  • There are potential benefits and risks of videoconferencing (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). The exceptions to client confidentiality policies that exist for regular therapy, also apply to Telepsychology services. If you need information on those exceptions, please consult the Confidentiality & Duty to Report page.

  • We agree to use the video-conferencing platform, Zoom, for our virtual sessions. Please visit the Telepsychology Services page for information and instructions on using Zoom.

  • Technology Requirements: You need to use a computer with internet access and webcam ability 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. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

  • It is important to use a secure internet connection rather than public/free Wi-Fi.

  • I understand there may be risks to telehealth psychotherapy, including but not limited to: poor internet connections, technical difficulties, power failures in the middle of a session, etc.

  • I understand that if there is a loss of transmission, my therapist will call me on the phone to complete the session.  Phone sessions may not be covered by your insurance company.

  • In the event of technical problems, 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 a crisis situation, we need a safety plan that includes at least one emergency contact and the closest emergency room to your location.

  • It is important to be on time. If you need to cancel or change your telepsychology appointment, you must notify the psychologist in advance by phone or email.

  • If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in telepsychology sessions.

  • 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.

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

  • The laws and professional standards that apply to regular psychological services apply to Telepsychology services

  • I understand that this informed Consent for Telepsychology Services is only in addition to my Informed Contract and Consent for Psychological Services and does not replace it in any way.

I agree that I have read (or had read to me) and agree to all items within the CONSENT FOR TELEPSYCHOLOGY SERVICE form. I have had the opportunity to discuss and ask questions about the content of this form, and have had my questions, if any, answered.  I am also aware that I can revoke consent at any time

Thanks for submitting!

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