PRIOR TO STARTING VIDEO-CONFERENCING SERVICES, WE DISCUSSED AND AGREED TO THE FOLLOWING:• There are potential benefits and risks of 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 other person(s).• We agree to use the video-conferencing platform selected for our virtual sessions, and the counselor 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 the counselor in advance by phone or email. Cancellation charges for less than 36 hour notice still apply ($75.00 and not billable to insurance)• 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.• My back up telephone number is: ten digit telephone number in case we are disconnected* • 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.• My emergency contact person & phone number is: My emergency contact’s full name/telephone number* • My closest ER is: Name of the nearest ER to my current location* • 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.• As the patient’s parent/legal guardian, I give consent for below named patient to participate in telepsychology counseling treatment. I will provide written notice to the assigned counselor if I choose to terminate this consent at any time. Counselor will have permission to complete one medically necessary termination session with patient. Name of parent/legal guardian* Signature* Date* • 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 counselor, I may determine that due to certain circumstances, telepsychology is no longer appropriate and that we should resume our sessions in-person.