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Consent for Telehealth Services

Videoconferencing & Telehealth Psychotherapy – Policy Implementation 3/17/2020
Addendum to Informed Consent for Psychotherapy and Therapist-Client Services Agreement

This form is to educate my psychotherapy clients about videoconferencing and telehealth psychotherapy sessions. When we cannot meet in person due to health or other concerns, videoconferencing is an option available to us. Your signature below indicates understanding and consent to videoconferencing and telehealth psychotherapy with Jenn Pagone, LCPC.

Technology for Videoconferencing Sessions
Videoconferencing psychotherapy sessions are provided on HIPAA-compliant platforms. I use Zoom, VSee, and Signal. These platforms allow for real-time video communication. These platforms are free to you. However, you will need a computer, a tablet or a phone with a video-camera and microphone. I use different platforms depending upon your preference and it is important always to have a back-up in case of technical issues. You and I will decide which platform we will use on an ongoing basis. It is important, however, that you download each of these on your phone, tablet, or computer for easy accessibility.


Limitations Due to Use of this Technology
A variety of technological problems can cause delays in starting meetings or can interrupt a meeting. If case we lose our connection, please call 773-339-7949. Keep your cellphone with you while we meet (should you be on a computer or tablet) so that I may call you if needed. If we cannot successfully reconnect on the internet, we can reschedule or continue on the telephone (telehealth session).

The audibility of videoconferencing is usually not as good as in face-to-face meetings. Participants may need to ask each other to repeat what is said. We will also be less able to observe each other’s body language. All of this can result in a less “felt” sense of each other as compared to meeting face-to-face. If you sense that I have missed your meaning or responded in an unhelpful way, please tell me as soon as possible so that we can work to repair the mis-communication or mis-step.

Confidentiality Caveats
Communication via the internet cannot be guaranteed to be 100% secure. The following are steps that we can take to increase security and confidentiality. Please "agree" to each bullet point below to indicate understanding and intent of compliance.

I Agree
The videoconferencing platform and related software are HIPAA-compliant and encrypted.
I Agree
We both agree not to record our videoconference meetings.
I Agree
To prevent non-participants from joining our confidential meetings electronically, we must both secure the links to our meetings that I send to you via encrypted email or through the encrypted Signal app or through VSEE or through ZOOM. Ensure your email account and mobile device have secure passwords and please log out and close these platforms when not in use. I will do the same.
I Agree
We both agree not to have any other people in the rooms where we hold our video or phone-conference. You must inform me immediately should another person enter your room. If I suspect there is another person present, I reserve the right to ask you to pan the room with your camera. I reserve the right to terminate a session if privacy is not upheld.
I Agree
Interruptions at home tend to occur during videoconferencing sessions and we should anticipate these. You can limit interruptions by telling people in your home that you are having a confidential meeting, close the doors to your room, lock the door, and place a “Do Not Disturb” sign on your doors. Nonetheless, people may forget and walk in, other phone lines and doorbells ring, pets make their presence known, etc.

Payment for Sessions

I Agree
Insurance companies are covering telehealth services. I will continue to submit all claims electronically. You are responsible for all co-pay and co-insurances. Payment is due on the date of service. I do not keep credit cards on file. Payment is requested through Zelle (jennpagone@yahoo.com) or Venmo (@Jenn-Pagone). You have access to your balance through the client portal. You are responsible for tracking your account balance.

Cancellations
Given the demands of the current health crisis, there are many individuals needing services or increased services. I ask that you please respect my time and the needs of other clients by committing to your scheduled appointment. If you are unable to keep your scheduled appointment and cancel under 24 hours due to a non-emergency, my 24-cancellation policy will apply with a fee of $50 due prior to your next scheduled session. Should you cancel your appointment on the same day of your appointment the fee is $75 due prior to your next scheduled session.

Agreement Specifics
I have read the above information on videoconferencing and telehealth psychotherapy, the limitations, and confidentiality caveats. With this understanding, I wish to participate and consent in videoconferencing and telehealth psychotherapy sessions with Jenn Pagone, LCPC when health or other concerns prohibit our being able to meet in person. Please "agree" below to indicate understanding and agreement.

I Agree
I understand that videoconferencing and telehealth psychotherapy includes the practice of health care delivery, including diagnosis, consultation, treatment, and education using interactive audio, video, and/or data communication.
I Agree
I understand that all protections and limitations of HIPAA are the same for online therapy as they are in person.
I Agree
I understand that I may need to download an application to use this platform. I also need to have a broadband Internet connection or a smart phone device with a good cellular connection at home or at the location deemed appropriate for services. The secure, HIPAA compliant server can be used to be used from a computer OR from a phone/tablet.
I Agree
I understand that I need to be in a private location where my sessions cannot be overheard by others. To ensure my privacy, I will use headphones or adjust the volume on my device, I will minimize background noise and other distractions, and will I inform Jenn Pagone, LCPC if there is anyone else in the room with me or if I believe someone may have overhear the session. I will be in an enclosed area to protect my privacy and confidentiality. I understand that Jenn Pagone, LCPC will also take these same precautions.
I Agree
I understand that I will not invite others into session time without discussing this with Jenn Pagone, LCPC first.

 

Client Rights

I Agree
I understand that I have the following rights with respect to videoconferencing and telehealth psychotherapy:

I have the right to withdraw consent at any time without affecting my right to future care or treatment.
The laws that protect the confidentiality of my medical information also apply to videoconferencing and telehealth psychotherapy. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality including, but not limited to: if I’m going to hurt myself or hurt others; reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.
I understand that there are risks and consequences from videoconferencing and telehealth psychotherapy. These may include, but are not limited to, the possibility, despite reasonable efforts on the part of Jenn Pagone, LCPC, that: the transmission of services could be disrupted or distorted by technical failures; misunderstandings can more easily occur, especially when care is delivered in an asynchronous manner; and/or possible confidentiality breaches if someone should walk into the client’s room during a psychotherapy session.
In addition, I understand that videoconferencing and telehealth psychotherapy based services and care may not yield the same results nor be as complete as face-to-face service. I understand that it is my responsibility to express any thoughts or feelings related to this to Jenn Pagone, LCPC so this may be processed.
I understand that I may benefit from videoconferencing and telehealth psychotherapy, but results cannot be guaranteed or assured.
I understand that in the case of an emergency, I will call 911 and/or go to my local emergency room. I also understand that Jenn Pagone, LCPC is not an on-call clinician and may not be immediately available should there be a crisis.

First Clients Name

First Name*

Last Name*

Phone*
First Clients Date of Birth*
I certify that I am 18 years of age or older
First Clients Signature*
Second Clients Name

First Name*

Last Name*

Phone*
Second Clients Date of Birth*
Second Clients Signature*
Third Clients Name

First Name*

Last Name*

Phone*
Third Clients Date of Birth*
Third Clients Signature*
Fourth Clients Name

First Name*

Last Name*

Phone*
Fourth Clients Date of Birth*
Fourth Clients Signature*
Fifth Clients Name

First Name*

Last Name*

Phone*
Fifth Clients Date of Birth*
Fifth Clients Signature*
Sixth Clients Name

First Name*

Last Name*

Phone*
Sixth Clients Date of Birth*
Sixth Clients Signature*
Seventh Clients Name

First Name*

Last Name*

Phone*
Seventh Clients Date of Birth*
Seventh Clients Signature*
Eighth Clients Name

First Name*

Last Name*

Phone*
Eighth Clients Date of Birth*
Eighth Clients Signature*
Ninth Clients Name

First Name*

Last Name*

Phone*
Ninth Clients Date of Birth*
Ninth Clients Signature*
Tenth Clients Name

First Name*

Last Name*

Phone*
Tenth Clients Date of Birth*
Tenth Clients Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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