Here it is, coronavirus or not, the order of the day is “Social Distancing.”

Switching to “online care” involves both social and technical adjustments.
Most of these are covered briefly in the Informed Consent Form (see below).

Please add your contact information, review the terms, then click the Consent box and the Submit button to accept.
(Click here for a blank PDF hard copy if you prefer.)

Consent for TelePsychological Services

In order to use video-conferencing services, we agree to the following details.
  • MM slash DD slash YYYY
  • There are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions.

    1. Confidentiality still applies for telepsychology services, and nobody will record the session without the permission from the others person(s).
    2. We agree to use the video-conferencing platform selected for our virtual sessions, and Dr. Turnbull will explain how to use it.
    3. You need to use a webcam or smartphone during the session, with data limits and power to last.
    4. It is important to be in a quiet, private space that is free of distractions.
    5. It is important to use a secure internet connection rather than public/free Wi-Fi.
    6. It is important to be on time. If you need to cancel or change your appointment, please notify Dr. Turnbull in advance.
    7. 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.
    8. We need a safety plan that includes at least one emergency contact and your location, in the event of a crisis situation.
    9. 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 telepsychology sessions.
    10. 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.
    11. As your psychologist, I may determine that due to certain circumstances, telepsychology is not, or is no longer, appropriate and that we should resume our sessions in-person.

  • This field is for validation purposes and should be left unchanged.