Informed Consent for Video Tele-Conferencing
Paul Boone, MDIV, LPC, LMFT, LCDC
4131 SPICEWOOD SPRINGS RD. Bldg. P, #2
AUSTIN, TEXAS 78759
(512) 452-0295 fax
Prior to staring video-conferencing services, 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 tele-psychotherapy services, and nobody will record the session without the written permission from the other person(s)
• We agree to use the video conferencing platform selected for our virtual sessions, and the therapist will explain how to use it.
• You need to use a webcam or smartphone and the Zoom app during the session.
• It is important to be in a quiet, private place that is free of distractions (including cell phone or other devices) during the session.
• It is important to have 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 therapist 48 hours in advance to avoid being charged.
• We need a back-up plan (e.g. personal phone number) to restart the session or to reschedule it, in the event of technical problems.
• We need a saftety 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 legally an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in tele-psychotherapy sessions.
• It is your responsibility to 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 therapist, I or we may determine that due to certain circumstances, tele-psychotherapy is no longer appropriate and that we should resume in-person sessions.
We agreed that for the purposes of connection and payment, you will entrust me with your email, cell number and chipped credit card number, expiration date, security number and zip code.
Client Signature: _____________________________