Robert A. Berley, Ph.D., C.G.P.
1314 NE 43rd Street, #214 (206) 935-4573
Seattle, WA 98105 e-mail: rberley@uw.edu
Telehealth Information and Agreement
This adds to the information and agreements from the Office Policy statement which you have previously read and signed.
Virtual “face-to-face” sessions or Video Conferencing is a real-time interactive audio and visual technology that enables a clinician to provide mental health services remotely. Treatment through Video Conferencing may be a preferred method due to convenience, distance, or other special circumstances. The Conferencing system used in my practice (Zoom) meets HIPAA standards of encryption and privacy protection. You will not have to purchase a plan or provide your name when you “join” an online meeting.
I will send you an “invitation” that contains a link to the Zoom site. When you click on that link, you’ll be taken to a virtual “waiting room” and I’ll “meet” you there at our appointed time. You’ll find tools there to check your audio volume and video quality.
Please read and take note that:
· There are many benefits and some risks of video conferencing that differ from in-person sessions.
· Confidentiality agreements that are always integral to your care, are the same for telepsychology services.
· Recording of sessions is NOT permitted.
· A camera needs to be used during the session. All cell phones and most laptops have cameras, while many stand-alone computer screens do not and require a separate web camera.
· 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 enforce your own right to privacy: no person, for example a family member or friend, should be within hearing or visual proximity to you or to your electronic device during the session.
· It is important to have a secure internet connection – do not use a public/free Wi-Fi.
· In order to be punctual please set up your computer or phone for the appointment at least 5 minutes before it is due to begin. You can click the link at any time and “wait” for me to start our session.
· A back up plan in the event of technical problems may include restarting the session, or more using a phone and just having an audio session.
· During the current health crisis, most insurance companies are following Medicare and reimbursing for telehealth services. You may wish to confirm that with your insurance provider.
Your signature here below indicates that you have read and understood this Telehealth Informed Consent Agreement.
Client name: ___________________________________________
Client signature ________________________________________ Date ____________________