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INFORMED CONSENT FOR TELE-MEDICINE SERVICES I, _____________________, (patient's name) hereby consent to telemedicine services with Arthur G Hamblin, Psy.D. as part of my psychotherapy. I am being informed that there are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions. With on-line or telephone therapy there is a question of where the therapy is occurring - at the therapist's office or the location of the client. The law is not yet completely settled on this issue, therefore it is my policy to inform patients that they are receiving services from my on-line office (as if they were physically present in a physical office) and therefore are bound by the laws of the State of Idaho. These laws are primarily related to confidentiality as outlined in this form and my disclosure form. Confidentiality still applies for tele-psychology services, and nobody will record the session without clear and stated permission. We agree to use the video-conferencing platform selected for our virtual sessions, and the psychologist will explain how to use it. It is important to be in a quiet, private space that is free of distractions (including cellular telephone or other devices) during these sessions. It is also important to use a secure internet connection rather that public/free Wi-Fi. It is important for both parties to be on time. If either needs to change the tele-appointment each person must give the other notification by telephone. We will need a back-up plan (e.g. telephone number where you can be reached) to restart the session or reschedule said session, in the event of technical problems. As your psychologist, I may determine that due to certain circumstances, tele-psychology is no longer appropriate and we should continue our sessions in person. This decision will be made jointly by us.
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