COMPLETED FORMS FOR TELEHEALTH SERVICES

Informed Consent

This agreement is intended as a supplement to the general Office Policies and does not amend any of the terms of the Office Policies agreement.
Your name typed below indicates agreement with its terms and conditions. By typing my name below, I am signing the Informed Consent Release electronically. I agree that typing my name is the legal equivalent of my manual signature on this form.
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First Name Last Name
*

Month Day Year
Date
E-mail & Texting Release
Email
example@example.com
Phone Number
My name typed below indicates that (1) my therapist and I may occasionally communicate by e-mail or text and (2) I understand that the confidentiality of e-mail or text transmissions cannot be totally protected. Information may be sent to me at the e-mail address listed above or by text on the cell phone number I have listed. You may revoke this authorization at any time in writing. By typing my name below, I am signing this form electronically. I agree that typing my name is the legal equivalent of my manual signature on this form.
Client Name
*

First Name Last Name
*

Month Day Year
Date
Are you a new client?

Yes No
Who are you scheduled to see?
Type Name here
Who is your therapist?
Type name here
Click Next below to continue...

EMERGENCY PLAN FOR TELEHEALTH SERVICES
In Case of an Emergency:

Life Threatening: Call 911

Urgent Situation: Call 302-428-0205, then press 9

For other psychological emergencies, you may also contact one of the emergency numbers listed below:
- Call Lifeline at (800) 273-8255 (National Crisis Line)
- Psychiatric Mobile Crisis (302) 577-2484 (New Castle County, Delaware)
- Rockford Behavioral Health Center (302) 996-5480 (Delaware)
- MeadowWood Behavioral Health System (302) 328-3330 (Delaware)
For your safety in an emergency, following are the procedures specific to telehealth.
1. Emergency Contact Person (ECP)

I require an ECP who I may contact on your behalf in a life-threatening emergency only. If you are in a crisis that we cannot solve remotely, I may determine that you need a higher level of care and that Telehealth services are not appropriate.

Please list your Emergency Contact Person (ECP) here:
First Name Last Name
Relationship to you
Telephone Numbers for ECP:
Cell
Home
Work

2. At the beginning of every session, you agree to inform me of your phone number and location. By typing my name below, I am signing this form electronically. I agree that typing my name is the legal equivalent of my manual signature on this form.

By typing my name below, I agree to the above statement.
Full Name *
Type your full name
Date *

Month Day Year
Date
3. For our Telehealth records, please list your telephone numbers and home and work address below.
Cell Number
Home Number
Work Number
Home Address

Work Address

City State

Zip Code
Work Address

Street Address Line 2

City State

Zip Code

BILLING AUTHORIZATION FOR TELEHEALTH
Billing for all telehealth services will be by credit card unless prior arrangements have been made with your therapist or the office staff. We do not accept debit cards or American Express cards.

We will keep your credit card on file and use it after each session for copays, deductibles and/or the session fee. The credit card information you provide will be stored in our payment processing system which is encrypted and HIPPA compliant.

Credit Card Authorization:

Charges for telepsychology appointments with my therapist from Associates in Health Psychology will be paid by using a credit card within 2-3 days of your session. By typing my name, using my electronic signature, or signing below, I authorize my AHP therapist or the AHP office staff to charge my credit card to pay my copay, deductibles and other fees related to my telepsychology sessions. I also allow “signature on file" to appear on my credit card receipt so it will not be necessary for me to sign receipts. I understand that my information will be saved for future transactions on my account.

You may cancel this authorization at any time by notification in writing to your AHP therapist or the AHP office staff. This authorization will remain in effect while utilizing telehealth or until canceled. When you are at an AHP office for sessions, your therapist will need to swipe your credit card. If you wish to continue to have “signature on file,” you will not need to sign your credit card at each visit.

YOUR THERAPIST WILL ASK FOR YOUR CREDIT CARD INFORMATION PRIOR TO, OR AT THE TIME OF, YOUR FIRST TELEHEALTH SESSION. PLEASE SIGN BELOW INDICATING YOUR AGREEMENT TO THE ABOVE POLICIES. By typing my name below, I am signing this form electronically. I agree that typing my name is the legal equivalent of my manual signature on this form.
Full Name *

First Name Last Name
Date *

Month Day Year
Date
Personal Email *
Personal Email Address for Payment Receipts
Your receipt will list Associates in Health Psychology and indicate that the amount was a payment for services.
Should be Empty:

Informed Consent

E-mail & Texting Release

EMERGENCY PLAN FOR TELEHEALTH SERVICES

In Case of an Emergency:

Life Threatening: Call 911

Urgent Situation: Call 302-428-0205, then press 9

For your safety in an emergency, following are the procedures specific to telehealth.

1. Emergency Contact Person (ECP)

Please list your Emergency Contact Person (ECP) here:

BILLING AUTHORIZATION FOR TELEHEALTH