I understand and agree to the following:
* The potential benefits and risks of telepsychology (e.g. limits to patient confidentiality) that differ from in-person sessions.
* Confidentiality still applies for telepsychology services and no one will record the session without my permission.
* It is important for me to be in a quiet, private space that is free from distractions during the session.
* For video-sessions only, it is important for me to use a secure internet connection. I will not use public/free Wi-Fi. Email is required for video sessions.
* It is important to be on time for sessions. If I need to change or cancel my tele-appointment, I will notify the CPD office in advance by phone or email.
* A safety plan is required. This includes at least one emergency contact and the closest ER to my location, in the event of a crisis situation. (For a minor, this needs to be a parent or guardian).
* If I am a minor, my parent or guardian will consent for me to participate in telepsychology sessions.
* My therapist may determine that, due to certain circumstances, telepsychology is no longer appropriate and that in-person sessions will resume or alternative treatment planning will be considered.
* I will contact my insurance carrier (if commercial provider) and ask if "TeleHealth" sessions are a covered service on my plan. (Member phone numbers are on the back of the insurance card). If TeleHealth service is provided, I will ask if the deductible applies or if there is a Co-Pay or Co-Insurance for which I am responsible.
* Tele-sessions will be billed to my insurance provider (video-call sessions only) or there will be an agreed upon self-pay amount. If my insurance provider does not reimburse for video-sessions, I am responsible for full payment. For phone sessions, I am responsible for full payment of the agreed upon self-pay amount. Payment for video & phone sessions (co-pays or self-pay are expected prior to the session). This does not apply to Medicaid.