Telehealth Via Video Conferencing Agreement
Download a PDF copy instead of filling in the form below.
Telehealth video conferencing is a real time interactive audio and visual technology that enables me to provide psychological services remotely. The system I use, VSee Messenger, meets HIPAA standards of encryption and privacy protection. After I receive your email address and client info, I will send you a link so that you are able to sign up for VSee Messenger and will be able to download it to your device from your app store. You will not have to purchase a plan or provide your name when you “join” an online meeting. Although teletherapy may be used when the clinician and client are in different locations, Maryland licensure regulations only allow a session to be conducted when both the client and psychologist are located in the state of Maryland.
Many insurance companies allow teletherapy sessions to be covered. Since I do not participate with insurances, you will need to check with your insurance to see if you are eligible for out of network benefits for telehealth. Phone sessions for current clients are also available and some insurances are reimbursing for telephone sessions, but vary, so please contact your insurance carrier.
Risks may include (but are not limited to): lack of reimbursement by your insurance company, the technology dropping due to internet connections, delays due to connections or other technologies, or a breach of information that is beyond our control. Clinical risks will may include discomfort with virtual face-to-face versus in-person treatment, difficulties interpreting non-verbal communication, and importantly, limited access to immediate resources if risk of self-harm or harm to others becomes apparent.
By signing the document below, you are stating that you agree to use video conferencing, are aware of the above risks, and that I may contact the necessary authorities in case of an emergency. You are also acknowledging that if you believe there is imminent harm to yourself or another person, you will seek care immediately through your own local health care provider or at the nearest hospital emergency department or by calling 911. Below, please include the names and telephone numbers of your local emergency contacts (may include local physician; crisis hotline; trusted family, friend, or confidant).
