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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.

I understand that I have the following rights with respect to tele-medicine:

(1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment, nor risking the loss of any program benefits to which I would otherwise be entitled.

(2) The laws that protect the confidentiality of my medical information also apply to tele-medicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to, reporting child, elder, and dependent adult abuse, and expressed threats toward another person.

I also understand that the dissemination of any personally identifiable images or information from the tele-medicine interaction to researchers or other entities shall not occur without my written consent.

(3) I understand that there are risks and consequences to tele-medicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychotherapist, that the transmission of my medical information could be disrupted or distorted by technical failures, the transmission of my medical information could be interrupted by unauthorized persons.

(4) I understand that I may benefit from tele-medicine but the results cannot be guaranteed or assured.

(5) I understand that I have the right to access my psychotherapy information and said records in accordance with Idaho law.

I have read and understand the information provided above. I have discussed any questions with my psychotherapist and all my questions have been answered to my satisfaction.

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