INFORMED CONSENT CHECKLIST FOR TELEHEALTH SERVICES
*including Teletherapy and Telepsychological services*

Prior to starting video-conferencing services, we discussed and agreed to the following:

There are potential benefits and risks of videoconferencing (e.g. limits to patient confidentiality) that differ from in-person sessions.

Confidentiality still applies for telehealth services, and nobody will record the session without the permission from the others person(s).

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

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