Initial Consultation Request Form

Initial Consultation - Appointment Request Form

Please provide information below to request a free initial consultation. Once confirmed, I will email you a telehealth link for our session. I look forward to speaking with you soon!
Name

First NameLast Name
Are you requesting services for yourself or a child?

MyselfChild
If you are requesting services for a child, then please include the child's name here:

First NameLast Name
Child's age:
Email
example@example.com
Do you consent to receiving emails from Texas Child Psychological Services, PLLC at this address?

YesNo
Phone Number
Please enter a valid phone number.
Do you consent to receiving calls or texts from Texas Child Psychological Services, PLLC at this number? (message and data rates may apply)

Yes - Both phone and text messagingYes - Phone onlyYes - Text onlyNo
Location
How did you hear about Texas Child Psych?
Please tell me a little about what you are hoping to explore during our initial consultation (e.g., questions you may have, what you are hoping to learn with an assessment, is the service for you or your child):
Appointment
CONSENT FOR TELEHEALTH CONSULTATION

1. I understand that my health care provider wishes me to engage in a telehealth consultation.

2. My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.

3. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

5. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

CONSENT TO USE THE TELEHEALTH BY SIMPLEPRACTICE SERVICE

Telehealth by SimplePractice is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:

1. Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.

2. Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.

3. The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date.

4. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.

5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

By signing this form, I certify:

That I have read or had this form read and/or had this form explained to me.
That I fully understand its contents including the risks and benefits of the procedure(s). That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
Signature

Clear
Should be Empty:

Initial Consultation - Appointment Request Form