Video Telepsychological Consent Form


This is a checklist and consent for conducting video/telepsychological sessions with Dr Malcolm E. Anderson.
Prior to starting video/telepsychological therapy sessions I suggest we agree on the following:

1. There are potential benefits and risks to video/telepsychological therapy (e.g., convenience, limits to patient confidentiality) that differ from in‐person sessions.
2. Confidentiality still applies for video/telepsychological therapy and we agree that recording sessions should be a mutual decision with granted permission from the patient and any others involved in the therapy.
3. We agree to use the video/telepsychological platform selected for our virtual session, and Dr. Anderson will explain which platform and how to use it. Dr. Anderson will strive to update the use of these platforms to meet HIPPA compliance and the safety of the patient’s personal health information (PHI).
4. While it is strongly preferred you use a laptop or PC with a webcam, a smartphone will suffice for the sessions. Smart phones are less secure and the signal is interrupted by incoming calls and texts.
5. It is very important that prior to beginning your session you find a location that is private, has a secure and strong internet or wireless connection, and a fast download/upload rate. Please make sure the location is free of distractions and has been tested prior to your session.
6. At this time, Dr. Anderson is licensed to practice in the State of Georgia and can not conduct sessions if the patient is out of state. In emergency situations this may be allowed but it is the exception not the rule.
7. It is important to be on time for your session. I will conduct hourly sessions at the top of the hour. If you need to cancel or reschedule your appointment, please abide by the 24‐hour rule detailed in your signed Therapeutic Service Agreement. You may contact me via text message, phone or email.
8. Prior to conducting video/telepsychological sessions we need to agree on a back‐up plan in the even of technical problems or disconnection. In the event of a disconnection we may agree to restart or reschedule the session depending on the situation and the percentage of the session completed.
9. If you are not in your home, we need to agree upon a safety plan that includes an emergency contact and the nearest most accessible hospital emergency room to your location.
10. If you are not an adult, (not yet 18 years old), we need the permission of your parent or legal guardian, and their contact information before conducting video/telepsychological therapy sessions.
11. You should confirm with your insurance company that video/telepsychological sessions will be reimbursed prior to conducting them. The patient is responsible for full payment of every session. A method of payment will be agreed upon prior to conducting sessions.
12. As your psychologist, I may determine that due to a change in clinical or environmental circumstances, video/telepsychological therapy sessions are no longer appropriate and that we should resume in person sessions. This decision will be made with safety and clinical benefits considered.
By reviewing and signing this document the patient agrees to the prescribed conditions and procedures that are essential for maintaining a video/telepsychological therapy relationship.

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