Assessment and Therapy Associates of Grand Forks, PLLC 
3535 South 31 St., Suite 201 Grand Forks, North Dakota 58201 
(701) 780-6821 (phone) | (701) 780-1973 (fax) 
www.grandforkstherapy.com | info@grandforkstherapy.com

 

**PLEASE NOTE: This paperwork is ONLY for individuals who have a currently scheduled appointment with a professional at our office. If you want to schedule an appointment, please contact our office at (701) 780-6821, so we can discuss the most appropriate options for you.**

Welcome to our practice! We are excited to work with you!

Please complete this paperwork at least 24 hours prior to your telehealth appointment, so we can send you the HIPAA-secure link for your session. 

To protect your information and verify your identity when using this form, we require you to upload a picture of a photo ID card (driver's license, student ID, etc.) that belongs to you (the patient) or a parent/legal guardian (for patients under 18yo).

If you are not comfortable filling out this form online using this HIPAA-secure, encrypted format, or are unable/unsure how to upload picture of your photo ID, please contact our office at (701) 780-6821 to receive this form in a different format (paper version or fillable PDF). 

This paperwork is not monitored in real-time. Therefore, if you need urgent help, please use one of these 24/7 crisis hotline numbers:

• 988 Suicide & Crisis Lifeline: call or text 988
• Northeast Human Service Center (Grand Forks county: 701-775-0525
• University Counseling Center (for UND students): 701-777-2127 (after 4:30pm press "1" for FIRSTLINK)

For additional crisis resources in North Dakota, visit North Dakota Behavioral Health & Human Services. 

For additional crisis resources in Minnesota, visit Minnesota Mental Health Crisis Line Numbers.

Please note that you are responsible for ensuring that the primary contact email on this form is the same email that is on file with our office staff as the primary email contact.

If you are not sure which email address is the primary email address on file, call our office at (701) 780-6821 to confirm. The email on file with office staff as the primary email is the one that will be used for all correspondence unless you make specific alternative arrangements with office staff.

If you desire alternative arrangements (Example: you want correspondence sent to one email address and telehealth links sent to another email address), you are responsible for speaking with our office to make these special arrangements. To make these arrangements, call (701) 780-6821.

Email can be a useful method of correspondence for clients, and it is how your HIPAA-secure session link will be shared with you for telehealth sessions. Transmitting confidential information by email can create several risks, both general and specific that clients need to be aware of if they choose this method of correspondence.

General email risks include but are not limited to the following:

• Email can be immediately broadcasted worldwide and received by many intended and unintended recipients;
  
  
• Recipients can forward email messages to other recipients without the original sender’s permission or knowledge;
  
  
• Users can easily send an email to the incorrect address;
  
  
• Email is easier to falsify than handwritten or signed documents;
  
  
• Backup copies of email may exist even after the sender or recipient has deleted his or her copy; and
  
  
• Without the benefit of face-to-face interaction, emails can be misinterpreted in tone and meaning.

Specific email risks include but are not limited to the following:

• Email containing information pertaining to a client’s diagnosis and/or treatment must be included in the client’s medical record. Thus, all individuals who have access to the medical record will have access to the email messages;
  
  
• If you are sending your emails from your employer’s or educational institution's computer and/or email account, your employer or educational institution does have access to your emails;
  
  
• While it is against the law to discriminate, an employer who has access to your email could use the information to discriminate against the employee. Additionally, the employee could suffer social stigma from a workplace disclosure;
  
  
• Insurance companies who learn of your PHI information could deny you coverage; and
  
  
• Although therapists and ATAGF staff will endeavor to read and respond to email correspondence promptly, they cannot guarantee that any particular email message will be read and responded to within any particular time frame.  Therefore, email should not be used for medical or mental health emergencies.

Conditions for use of email:

All email messages sent or received that concern your diagnosis or treatment or that are a part of your medical record will be treated as part of your PHI. Reasonable means will be used to protect the security and confidentiality of the email. Because of the risk outlined above, the security and confidentiality of email cannot be guaranteed. 

Your consent to email correspondence includes your understanding of the following conditions:

• All emails to and from you concerning your protected health information (PHI) will be a part of your file and can be viewed by health care, insurance providers, and ATAGF office support staff.
  
  
• Your email messages may be forwarded within ATAGF as necessary for diagnosis, treatment, and reimbursement. However, they will not be forwarded outside the office without your consent or as required by law.
  
  
• Though all efforts will be made to respond promptly, this may not be the case.  Because the response cannot be guaranteed do not use email in a medical or mental health emergency.
  
  
• You are responsible for following up with the therapist or support staff if you have not received a response.
  
  
• Medical information is sensitive and unauthorized disclosure can be damaging. You should not use email for communications concerning diagnosis or treatment of AIDS/HIV infection, other sexually transmittable diseases, mental health, developmental disability, or substance abuse issues. It is your right, however, to choose to communicate about this information if you desire.
  
  
• Since employers and educational institutions do not observe an employee’s or student's right to privacy in their email system, you should not use your employer’s or educational institution's email system to transmit or receive confidential emails.
  
  
• ATAGF will take reasonable steps to ensure that all information shared through emails is kept private and confidential. However, ATAGF is not liable for improper disclosure of confidential information that is not a result of our negligence or misconduct. 
  
  
• If you consent to the use of email, you are responsible for informing ATAGF and any professionals with whom you correspond of any type of information that you do not want sent to you by email.
  
  
• It is your responsibility to update your email address with ATAGF staff members and professionals if it changes.
  
  
• You are responsible for protecting your password and access to your email account and any email you send or receive from ATAGF to ensure your confidentiality. ATAGF and its staff members cannot be held liable if there is a breach of confidentiality caused by a breach in your account security.
  
  
• Any email that you send that discusses your diagnosis or treatment constitutes informed consent to the information being transmitted. If you wish to discontinue emailing information, you must submit a written notification to that you wish to discontinue or an email informing ATAGF or your provider(s) that you are withdrawing consent to email information. 
  
  
• If you are participating in telehealth, your HIPAA-secure link will be sent to you via email. Because not all ATAGF providers use email to communicate with patients, this email link may be sent to you by ATAGF office staff.

Because not all ATAGF providers communicate with patients and/or collaterals by email, please speak with your provider about whether they use email for communication.

This Informed Consent for Telehealth contains important information focusing on doing psychotherapy using the phone or the Internet. Please read this carefully, and let your professional or an ATAGF staff member know if you have any questions. When you sign this document, it will represent an agreement between you, your professional, and ATAGF.

Benefits and Risks of Telehealth 

Telehealth refers to providing psychotherapy services remotely using telecommunications technologies, such as video conferencing or telephone. One benefit of telehealth is that the client and professional can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or professional moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It is also more convenient and takes less time.

Telehealth, however, requires technical competence on the part of you and your professional to be helpful. Ultimately, as a client, you accept responsibility and acknowledge the risks of confidentiality in the environment in which you choose to participate in telehealth sessions. Although there are benefits of telehealth, there are some differences between in-person psychotherapy and telehealth, as well as some risks.  For example:

Risks to confidentiality. Because telehealth sessions take place outside of the professional's private office, there is potential for other people to overhear sessions if you are not in a private place during the session. Your professional will take reasonable steps to ensure your privacy on their end. It is important for you to make sure you find a private place for your session where you will not be interrupted. It is also important for you to protect the privacy of your session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation.

Issues related to technology. There are many ways that technology issues might impact telehealth. For example, technology may stop working during a session, there may be delays due to connection or other technology issues, other people might be able to get access to the private conversation, stored data could be accessed by unauthorized people or companies, or a breach of information that is beyond our control. 

Clinical risks. Clinical risks will be discussed with you in more detail with your professional but may include the following: discomfort with telehealth vs. in-person treatment, difficulties interpreting non-verbal communication, and limited access to immediate resources if risk of self-harm or harm to others becomes apparent. Your professional will weigh advantages to telehealth against any potential risks prior to proceeding with telehealth sessions and will discuss the specifics of telehealth with you prior to using the technology.

Crisis management and intervention. Usually, your professional will not engage in telehealth with clients who are currently in a crisis requiring high levels of support and intervention, although this is up to the discretion of each professional. Before engaging in telehealth, you and your professional will develop an emergency response plan to address potential crisis situations that may arise during your telehealth work.

Insurance reimbursement. Another risk to using telehealth is your insurance company may not reimburse for telehealth services. If you have a health insurance policy, it will usually provide some coverage for mental health treatment, although it may not cover telehealth services. However, many insurance companies have been known to change their policies to cover telehealth services in times of national emergencies (e.g., COVID-19). ATAGF administrative assistants and your professional will fill out forms and provide you with whatever assistance he/she can in helping you receive benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of your professional's fees. It is very important that you find out exactly what telehealth services your insurance policy covers.

Efficacy. Most research shows that telehealth is about as effective as in-person psychotherapy. However, this may vary based upon the condition being treated. Your professional will discuss the efficacy of telehealth with you and answer any questions you may have.

Electronic Communications

ATAGF clinicians use Zoom for Healthcare (www.zoom.us), which is a HIPAA-secure platform, for telehealth services. ATAGF maintains a Business Associate Agreement with Zoom, and as part of this agreement Zoom agrees to keep data secure. Zoom sessions have complete end-to-end 256-bit AES encryption. Zoom meets HIPAA standards of encryption and privacy protection, but ATAGF cannot guarantee privacy. You will not have to purchase a plan or to provide your name when you “join” your online meeting.

Beyond this, you and your professional will decide together if you use any additional kind of telehealth service. You may have to possess certain computer or cell phone systems to use telehealth services. You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software to take part in telehealth.

Some professionals may use email or text messaging for communication between sessions. This is only done with your permission and only for administrative purposes unless you have made another agreement with your professional. If you and your professional elect to communicate via email and/or text messaging, you will be asked to sign other document(s) where you give your informed consent to using these methods of communication.

Email exchanges and text messages with your professional and/or ATAGF should be limited to administrative matters. This includes things like setting and changing appointments, billing matters, and other related issues. You should be aware that ATAGF and its professionals cannot guarantee the confidentiality of any information communicated by email or text. Your professional will not discuss any clinical information by email or text and prefers that you do not either. ATAGF professionals and staff do not regularly check email or texts, nor do they respond immediately to these messages, so these methods should not be used if there is an emergency.

Treatment is most effective when clinical discussions occur at your regularly scheduled sessions. However, if an urgent issue arises, you should feel free to attempt to reach your professional by phone. Your professional will try to return your call within 24 hours except on weekends and holidays. If you are unable to reach your professional and feel that you cannot wait for them to return your call, contact the nearest emergency room and ask for the psychologist or psychiatrist on call. If your professional will be unavailable for an extended time, they will provide you with the name of a colleague to contact in their absence if necessary.

Confidentiality

Your professional has a legal and ethical responsibility to make his/her best efforts to protect all communications that are a part of your telehealth sessions. However, the nature of electronic communications technologies is such that your professional and ATAGF cannot guarantee that communications will be kept confidential or that other people may not gain access to these communications. ATAGF and your professional will use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that your electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of your communications (for example, only using secure networks for telehealth sessions and having passwords to protect the device you use for telehealth). 

The extent of confidentiality and the exceptions to confidentiality that are outlined in ATAGF’s Patient Services Agreement still apply in telehealth. Please let your clinician know if you have any questions about exceptions to confidentiality.

Location

Your professional is required to follow all applicable laws and rules on a state and federal level for the jurisdictions in which they are licensed or practicing. Therefore, your professional will ask you to identify your location at the beginning of your telehealth sessions. If your professional is not able to practice legally (e.g., not licensed) in the jurisdiction where you are located at the time of your session, they will reschedule the session. An occasional exception can be made if temporary permission is granted from another jurisdiction.

Entering Your Session

Your professional will provide you a link to enter your session. You will enter a virtual waiting room, and your professional will admit you to the session room at the time of your session. Your professional will not invite you into the room outside of your pre-determined session time, nor will your professional be available to you via the meeting room outside your pre-determined session time. If you need to reach your professional outside of your scheduled session time, please contact the ATAGF office at (701) 780-6821. Your professional may not be immediately available, so if it is an emergency, you agree to use the pre-determined emergency management plan to access immediate services.

Appropriateness of Telehealth

From time to time, you and your professional may schedule in-person sessions to “check-in” with one another. Your professional will let you know if they decide that telehealth is no longer the most appropriate form of treatment for you. Your professional will discuss options of engaging in in-person counseling or referrals to another professional in your location who can provide appropriate services.

Emergencies and Technology

Assessing and evaluating threats and other emergencies can be more difficult when conducting telehealth than in traditional in-person therapy. To address some of these difficulties, you and your professional will create an emergency plan before engaging in telehealth services. Your professional will ask you to identify an emergency contact person who is near your location and who your professional will contact in the event of a crisis or emergency to assist in addressing the situation. Your professional will ask that you sign a separate authorization form allowing your professional to contact your emergency contact person as needed during such a crisis or emergency.

If your telehealth session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call your professional back; instead, call 911 or go to your nearest emergency room. Call your professional back at (701) 780-6821 after you have called or obtained emergency services.

If the session is interrupted and you are not having an emergency, disconnect from the session and your professional will wait two (2) minutes and then re-contact you via the telehealth platform on which you agreed to conduct telehealth (Zoom). If you do not receive a call back within two (2) minutes, then call the ATAGF office (701-780-6821) and ask to speak to your professional.

If there is a technological failure and you are unable to resume the connection, you will only be charged the prorated amount of actual session time.

Fees 

The same fee rates will apply for telehealth as apply for in-person psychotherapy. However, insurance or other managed care providers may not cover sessions that are conducted via telecommunication. One caveat, however, is many insurance companies have been known to change their policies to cover telehealth services in times of national emergencies (e.g., COVID-19). If your insurance, HMO, third-party payor, or other managed care provider does not cover electronic psychotherapy sessions, you will be solely responsible for the entire fee of the session. Please contact your insurance company prior to engaging in telehealth sessions in order to determine whether these sessions will be covered. ATAGF does not charge any additional service or technology fees for telehealth services.  

Recordings & Records

The telehealth sessions shall not be recorded, photographed, or screenshot in any way by any party unless agreed to in writing by mutual consent. Your professional will maintain a record of your session in the same way they maintain records of in-person sessions in accordance with ATAGF policies. If you are meeting in a location with a home assistant and/or device that video and/or audio records (e.g., Google Nest, Furbo), it is your responsibility to ensure these devices are not recording you while you are engaged in telehealth sessions.

PSYPACT Services

If you reside outside of the state of North Dakota and are receiving services from a Licensed Psychologist through telehealth, your psychologist is authorized to provide these services under the authority of PSYPACT. This involves the provision of psychological services using secure electronic communications (e.g., video conferencing, phone when appropriate). Services may include assessment and diagnosis, treatment planning, psychotherapy, consultation and in using these services you agree to and understand the following:

Nature of Services: You are receiving psychological services via telehealth. Your provider is a Licensed Psychologist in North Dakota and authorized to practice in your jurisdiction through PSYPACT.

Provider Credentials: Your provider holds a license as a psychologist in North Dakota and the Authority to Practice Interjurisdictional Telepsychology (APIT) credential through PSYPACT.

Location Requirement: You must be located in a PSYPACT state and disclose your location each session.

Confidentiality: Your privacy is protected under HIPAA, with limits as outlined in the general Informed Consent and Telehealth informed consent documents, such as safety, abuse reporting, and court orders.

Risks of Telehealth: Risks of telehealth are outlined further earlier in this document and include technology failure, reduced nonverbal observation, and privacy concerns.

Emergency Situations: Provide your location and emergency contact to your psychologist. Call 911 in emergencies.

Licensure and Complaints: You may contact the North Dakota Board State of Psychologist Examiners (NDSPBE), the psychology licensing board of the state you are located in, or PSYPACT Commission with complaints.

Consent: By signing this document, you acknowledge understanding and consent to telepsychology services under the authority of PSYPACT, as applicable.

Informed Consent 

This agreement is intended as a supplement to the general informed consent that you agreed to at the outset of your work with your professional and does not amend any of the terms of that agreement. If you are unable to agree to or abide by these terms, your professional may elect to terminate telehealth services with you and refer you a professional who can provide face-to-face mental health services.

By signing the document below, you are stating that you are aware that your professional may contact necessary authorities in case of an emergency. You are also acknowledging that if you believe there is imminent harm to yourself or another person that you will seek care immediately through your own local health care professional, at the nearest hospital emergency department, or by calling 911.

By signing this document, you also acknowledge, as a client, that you accept responsibility and acknowledge the risks of confidentiality in the environment in which you choose to participate in telehealth sessions.

You have read this document and have had the opportunity to ask questions. You discussed this with your professional and understand the risks/limitations and benefits to telehealth services. You agree to telehealth sessions (CPT code includes the modifier of GT or 95; varies based upon insurance company) via videoconferencing or phone.

Your typed name and/or signature below indicates agreement with the telehealth terms and conditions presented in this document (in addition to the terms and conditions presented in the Patient Services Agreement signed at the outset of your relationship with ATAGF). By typing your name or signing electronically, you are effecting all the force of your legal, handwritten signature.