Informed Consent

Clinical Records

In the interest of providing competent psychological services at reasonable rates I limit my routine record keeping procedures to the professionally responsible minimum. This allows me to spend more time directly serving you and less time on paper work. If for any reason you would like a written summary of your treatment sent to another professional, I would be happy to prepare a narrative at the time of your request.

Confidentiality

Generally speaking, the confidentiality of your records is assured by state and federal law; that is, your records cannot be released without a written authorization from you. Other State laws may override confidentiality and mandate that critical situations be reported to governmental agencies in the following specific cases: 1) if a patient expresses a serious intention to harm himself or others, or 2) if there is a substantial concern that children or the elderly are being abused or neglected.

Confidentiality and Video Conference-Based Counseling

Confidentiality is obviously a central concern for counseling. Preserving patient privacy when using video conferencing requires that both the doctor and the

• The video conferencing tool that I have selected provides a secure connection between my computer and your smartphone, tablet or computer. Please avoid joining the call from an unsecured internet connection such as public or free Wi-Fi.

• My office is arranged to prevent others from listening in our your session. With video conferencing, you are responsible for selecting a location for your side of the connection that will keep our conversation private and free from background noise and distractions.

• I will not record any of your sessions. You are welcome, even encouraged, to record our sessions. I simply request that you obtain my permission before beginning to record.

• I do use video conferencing in situations where the patient is not an adult, but only with the permission of and in collaboration with the child’s parent or legal guardian. In these situations, it may be necessary for the parent or guardian to arrange for the child to communicate with me in complete privacy as well.

Insurance and Video Conference-Based Counseling

Insurance generally pays for video conference-based counseling just as it does for in-person psychological services. Your insurance contract may specify that you are responsible to pay for some or all of the cost of your treatment. For example, you may have a copayment for each session, or an unmet deductible that you must pay yourself before your insurance company begins paying your claims.

I encourage you to call the customer service number on your insurance card to determine the extent of your coverage for “tele-health mental health services.”

Of course, you are responsible for paying any unreimbursed charges.