Prior to starting therapy services through telephone or videophone, 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 of the others person(s).

- We agree to use the video-conferencing platform selected for our virtual sessions, and the psychologist will explain how to use it.

- For videophone, 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 psychologist in advance by phone or email.

- 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.

- 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.

- 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.

- 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 psychologist, I may determine that due to certain circumstances, telepsychology is no longer appropriate and that we should resume our sessions in-person.

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* I have read and understood all of these conditions and indicate my agreement below: