• 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.

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  • E-mail & Texting Release

  • 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.

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  • 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:

  • 2. At the beginning of every session, you agree to inform me of your phone number and location.

  • 3. For our Telehealth records, please list your telephone numbers and home and work address below.

  • 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.

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  • Your receipt will list Associates in Health Psychology and indicate that the amount was a payment for services.

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