VIDEO CONFERENCING AGREEMENT MAY 2023 *

After intake, you and your therapist may agree that virtual therapy via interactive video conferencing (VC) (Zoom Platform) may be an effective modality in lieu of, or in addition to, "in person" sessions. Video conferencing (VC) is real-time interactive audio and visual technology that enables clinicians to provide mental health services remotely. The VC system used (www.zoom.us) meets HIPAA standards of encryption and privacy protection but I cannot guarantee privacy. You will not have to purchase a plan or provide your name when you "join" our online meeting. Treatment delivery via VC may be a preferred method due to convenience, distance, or other circumstances. Given PSYPACT Regulations, VC may be used when the clinician and client are both in Maryland where the therapist holds a license, or if the client is in a state that is PSYPACT approved. Please understand that it is your responsibility to ensure that your child, teen, or you are in a private space with no one else in the room to maintain confidentiality. A headset is recommended if there is a concern of voice being heard from another room. Recording of sessions is not allowed at either end unless this is agreed upon. Further, I cannot guarantee that you or your child will be seen via telehealth if you change state locations as inter-jurisdictional regulations still apply. Risks with VC in general may include but are not limited to: lack of reimbursement by your insurance company, the technology dropping due to internet connections, delays due to connections or other technologies, or a breach of information that is beyond our control. Clinical risks may include discomfort with virtual face-to-face versus in-person treatment, difficulties interpreting nonverbal communication, and importantly, limited access to immediate resources if risk of self-harm or harm to others becomes apparent. As your therapist, I will weight these advantages against any potential risks prior to proceeding with telehealth sessions and we will discuss the specifics of telehealth before proceeding. By signing the document below, you are stating that you are aware that your provider may contact the necessary authorities in case of an emergency. You also acknowledge that if you believe there is imminent harm to yourself or another person, you will seek care immediately through your own local health care provider or at the nearest hospital emergency department or by calling 911. Below, please provide the names and telephone numbers of your local emergency contacts (including local physician, psychiatrist, trusted family/friend/partner, and crisis hotline).

I Agree

Name of Your Physician *

First Name

Last Name

Name of Your Psychiatrist *

First Name

Last Name

Phone *

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Name of a Trusted Family/Friend/Partner *

First Name

Last Name

Phone *

(###)

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Name of a Trusted Family/Friend/Partner

First Name

Last Name

Phone

(###)

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Phone

(###)

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