Important Note: You are not required to complete this form electronically. If you would prefer a paper copy to complete, please call us at (919) 600-4906.

3/18/2020: This document is specific to telehealth during the new coronavirus (also known as COVID-19) outbreak. We will return to our prior telehealth informed consent once the current public health crisis passes.

Please read carefully, and let us know if you have any questions. When you sign this document, it will represent an agreement between us.

Telehealth is sometimes called "telepsychology" or "teletherapy" when referring to mental health care and is the provision of mental health services using telecommunication (communication by electronic means) technology. We use secure video conferencing for our telehealth services. “You” in this document refers to the patient, and “we” refers to your mental health provider at Etheridge Psychology.

Risks and Benefits of Telehealth for Mental Health Care

The primary benefit of telehealth is the ability to access mental health care when access to face-to-face service is difficult or impossible.

Risks of telehealth may include, but are not limited to:

Technology risks: These risks include interruption of an appointment due to technical difficulty, user error, or service limitations in using telecommunications platforms. Our platform is user-friendly, but problems can occur. We have a back-up option if the primary platform fails. In some cases, we may be able to conduct your session via telephone (audio only). You must have your own device to use our telehealth services and are solely responsible for any cost to you associated with your device, software, accessories, and/or internet connection that you may need to participate.

Confidentiality risks: We will take our usual steps to ensure your privacy. You should find a private place for your appointment where you will not be overheard, even if that means sitting in your parked car during your appointment. You should also be aware of the risk of your computer, cell phone, or tablet being hacked.

Effectiveness: Most research shows that mental health counseling via telehealth is about as effective as in-person psychotherapy. That said, there is a risk that we may have difficulty observing and assessing important verbal, nonverbal, and behavioral signals and symptoms. Some patients may have difficulty feeling emotionally secure and connected during telehealth counseling sessions, but most people find telehealth to be comfortable and helpful.

How Secure and Confidential is Telehealth?

Mental health providers using telehealth are under the same ethical and professional standards of care as they are in face-to-face services. We will not allow anyone in the room with us while we are conducting telehealth appointments with you. We will use devices and software that comply with HIPAA standards for video conferencing. We will not record our sessions unless you have previously agreed for us to do so in writing. We will not capture screenshots or photos of you during our sessions. It is important for you to know, however, that even with our most diligent efforts at protecting your privacy in an electronic environment, we cannot guarantee that a breach is impossible.

Privacy extends to your computer or device as well as your environment. You should take steps to ensure that you are in a private place and not being overheard by others during your appointment. We cannot advise you as to whether the device you use for your appointment (e.g., your computer) is secure and protected.

The same limitations of confidentiality regarding in-person mental health services also apply to telehealth services. Examples: We are still required to report abuse of children, disabled adults, and elderly adults. We are still required to take steps to protect your life if you are at imminent risk of committing suicide. If you are a serious danger to someone else, we may be required to warn that person or contact law enforcement.

How Does it Work?

Telehealth works in much the same way as in-person appointments. Sessions are by appointment only and last roughly the same amount of time. There is nothing to download, and no login is required. We will simply email you a link that you click on when it's time for your appointment. You'll be connected to our HIPAA-compliant telehealth platform. You will need a computer, tablet, or cell phone with a camera, microphone, speaker, and a strong internet or cellular connection. If you have any problems, just call our office. 

Your clinician will conduct telehealth appointments from our mental health practice unless we tell you otherwise. For example, your clinician may conduct your appointment from their private home during the current COVID-19 outbreak. We will always ensure the same strict privacy guidelines as we use in the office. You must be physically located in North Carolina for us to be able to provide telehealth to you because professional licenses do not cross state lines.

How Much Does it Cost?

Fees for telehealth are the same as in-person appointments as outlined in the Financial Policies portion of the Psychological Services Agreement unless another agreement has been made. Most insurance companies have agreed to cover telehealth during the current coronavirus outbreak. As with any other health care provider, we cannot guarantee that services will be covered, but we will file your claims for you and seek reimbursement. 

I have read this document and understand the risks and benefits of using telehealth for my counseling session or evaluation.

I understand that this document is considered to be an addendum to, and not a replacement for, the Psychological Services Agreement that I signed (or will sign) at the beginning of my treatment and that all aspects of the Psychological Services Agreement remain in effect and apply to the provision of mental health services via telehealth. If you would like a copy of the Psychological Services Agreement that you previously signed, please ask.

I agree to allow mental health services to be rendered to me via telehealth, I understand I am not required to participate in telehealth, and I may return to in-office sessions when desired and/or possible.

I agree to allow Etheridge Psychology to email me, at the email address I provide here, information about telehealth appointments and how to access the telehealth platform. I understand that Etheridge Psychology cannot guarantee the security of our email communications and that there may be a risk of email being intercepted by third parties, such as by hacking. 

Electronic Signature

By completing the following fields, you affirm that you have read this document, that you agree to the terms and conditions, and that you consent to sign this document electronically. You are not required to sign electronically and may request this document in non-electronic form. You have the right to withdraw your consent to further electronic disclosures, in writing, at any time. You have the right to receive a copy of your completed form. You may reach us by phone at (919) 600-4906, and our address is 115 Kildaire Park Dr Ste 313, Cary, NC 27518. If you are signing this document on behalf of a legal dependent (such as a minor child), you attest that you have the legal authority to sign on behalf of this patient without the approval of another person (such as a minor's other parent).

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