(This document was adapted from the consent form shared by Julie A. Jacobs, PsyD, JD, and the one available on the Australian Psychological Society website)

 

INFORMED CONSENT FOR TELEHEALTH CONSULTATIONS

 

This Informed Consent for Telehealth contains important information regarding clinical sessions using the phone or the Internet. Please read this carefully, and let me know if you have any questions.  I will ask you about it during our session and note down that you have read it.

 

Safety considerations for telehealth consultations:

• .It is important for you to make sure you find a private place for our session where you will not be interrupted or overheard, and to protect the privacy of our session on your mobile phone or other device (i.e. with a password).

 

• Privacy and technology 

Emails and text messages are not secure. I will use email and text messaging for administrative purposes unless we have made another agreement.This includes things like setting and changing appointments, billing matters, and other related issues. Some Word documents will be password-protected (e.g. signed consent forms).

 

I will be using Zoom for video conferencing as it provides end-to-end encryption for data security and is APS and HIPAA compliant. I also have adjusted  the settings to ensure privacy.

 

• Crisis management and intervention. 

CLINICAL ISSUES:

We’ll work together to develop an emergency response plan to address potential crisis situations that may arise during the course of our work.

1. I will ask you to:

   • identify two emergency contact people who are near your location and who I will contact in the event of a crisis or emergency to assist in addressing the situation.

   • keep Lifeline and Mental Health Line accessible.

   • let me know your location for the session.

   • practise grounding skills in-between sessions if required.

 

 TECHNICAL ISSUES:

1. If the session is interrupted for any reason, such as the technological connection fails, and you are not having an emergency, please call me on 0400 553 160 so we can work together on reconnecting or complete the session by phone.

 

1. If the session is interrupted and you are having an emergency, do not call me back; instead, call your nominated support person or 000. Call me back after you have called or obtained emergency services.

 

Electronic Communications

Zoom videoconferencing instructions:

 

1. I will send an email with a link.

2. When you click on the link, it will ask you to download Zoom (if you don’t already have it) and then to join the meeting.

3. If you already have Zoom installed, it will ask you to join the meeting.

 

Fees

The normal fee is $___, and the Medicare rebate for the Focused Psychological Strategies (FPS) item number (___)  is $___. This means the cost to you is $___. The new Medicare rebate for telehealth FPS is $___. ($___out of pocket expense)

 

This consultation will be bulk-billed in the following circumstances, although this may change.

 

1. You are in quarantine or have been diagnosed with Covid-19 infection.

2. You are over 70.

3. You are pregnant or have a child under 12months of age.

4. You have a chronic heart or lung condition, or are immunocompromised.

5. You are under 16.

6. You have a Concession Card.

 

Please feel free to discuss this in our sessions.

 

Records

I will not make recordings of our sessions or use material from our sessions for purposes other than delivering a service to you. I will seek your written consent if I wish to use material for other purposes (such as consultation with colleagues).

 

I will ask you to respect my privacy by agreeing not to make recordings of our sessions and not to use materials from our sessions for purposes other than therapy. If you wish to record sessions or use session material for other purposes, you must seek my consent to do so.

 

Informed Consent

Reading the information in this document and obtaining verbal consent at our session constitutes informed consent.