Signed Electronically Online Therapy Consent Made Easy

Sign online therapy consent

Hi, I know that so many of my therapist friends are freaking out about the fact that Coronavirus is going around and it may impact their ability to see clients that they've been seeing face to face. I've been talking with University counseling centers who are also concerned about this because they're seeing hundreds of clients every week in their counseling center and some universities are shutting down to stop the spread of the virus and their concerned about not being able to provide ongoing care for their regular clients or clients who are in crisis. So I know that many of you are trying to make a very quick decisions about whether or not to provide telehealth, that is therapy provided by synchronous, meaning at the same time, video connection. So if you're thinking about that, I just wanted to make a quick and easy video to walk you through what you'll need to have in place to set that up so that it doesn't have to feel so scary and also so that you're not out there just kind of throwing things together. Willy-nilly. So let's get started. Yes, you do need to make sure that you have telehealth covered in your informed consent and just like any informed consent, you're gonna wanna cover risks and benefits of telehealth. Just like you cover risks and benefits of therapy in general. If you want a shortcut to what needs to be in your informed consent related to telehealth you can go to my website, AmberLyda.com. It's A M B E R L Y D A.com. Under my products section, you'll see my informed consent. You don't need to buy the informed consent. There's a free outline on that page for you so that you can look for exactly what needs to be in there. Okay. So number one you will wanna have paperwork in place and the previous informed consent that you previously had with your client needs to be updated to include some telehealth specific features. So again, just check out that piece of my website to see an outline of what needs to be there. Most states and most professional bodies like the American Psychological Association or the National Association of Social Workers. Most don't have out guidance statements or ethical statements about what needs to be in your informed consent related to telehealth specifically, but some of them do so it is worth Googling. So, step two, it's worth Googling your professional body and ethics, put those two words together and get that statement printed out. Read through it to look for tech related issues. So whether it be telehealth or whether it be social media statement and make sure that you have added that in to your updated informed consent and then I also want you to Google the name of your association and guidance statements because your professional ethics statement only gets updated every few years and so in between if something is changing a lot like the status of telehealth, then they're going to release a guidance statement prior to the next ethics release. So just look up, you know social work, guidance statement, telehealth and social work has a beautiful guidance statement about telehealth, so there's is like so good and you can even if you're from a different profession, grab some of the language from the there and put it in your informed consent. So we need to update our informed consent. You want to check with your professional body and their ethics statement or their guidance statement to see if there's anything that needs to be in there that you haven't thought of and you're also going to want to check with your state board to see if they have any statements about telehealth as it relates to your paperwork. So what I like to do is just print all of the stuff that my state board says that has anything to do with my practice of psychology and then just scroll through there with a highlighter and look for anything that might relate to my telehealth practice. Highlight that bad boy and if it's related to paperwork, then I can add that into my paperwork, but they're also gonna be some other things in there that relate to your practice of telehealth. So we're gonna come back to that in a minute. Also, related to kind of the paperwork administrative side is that you wanna make sure that your liability insurance will cover you for telehealth and many of them do now. I use APA Trust and they cover my telehealth practice. So you just wanna going to want to call your liability provider and ask them if they cover telehealth and if they will add that on to your policy. If they don't, don't stress because you can just switch to another liability provider and they'll cover your telehealth, but you wanna do two things. Make sure that they cover it and then add it and all that looks like you guys is printing out the application and adding telehealth onto the bottom and then emailing it back to them. My application turned around in 24 hours. So if you're concerned about like, oh my gosh, I'm not gonna have time, don't worry, it usually turns around really really fast. So you're informed consent, the outline is on my website, Google for your professional code of ethics and if there's anything in there that needs to be added, Google for your state licensing body, and if there's anything from there that needs to be added and then make sure before you go practicing telehealth that you've contacted your liability insurance provider and that they cover telehealth and that you've added it to your liability. Okay. I'm gonna pause so that you can breathe. Telehealth is a thing that's happening in all states, so there is no state that saying you can't practice online. Some states have some particular standards in place and when I mentioned printing out your state regulations, this is where that becomes important. So get your notes out. We're just gonna cover some important stuff here and I'm gonna try to go slowly so they don't overwhelm you. It's not a lot, but if you're brand new, it can feel a little bit cumbersome. So all states allow telehealth. Some states have specific requirements around whether or not you can practice it. So I want to start first with the most frequently asked question that I get which is do I need to be licensed in a state where I am or the state where my client is, if those two things are different? Most states require you to be licensed in the state where your client is, not where they're visiting, excuse me, not where they're going to College, not where their permanent address is, but where they are currently located at the time of therapy. And this makes logical sense because if you think about like if your client goes into crisis, what are you gonna do about that? Well, you don't know unless you know the laws of the place where they are, you don't know who to contact or what the involuntary hospitalization procedure would be or at what points you need to report suspected child abuse or elderly abuse because every state is slightly different and their process is slightly different. So that kind of makes intuitive sense to me that where my client is is where I need to be licensed and that's the case in most states. You'll wanna check in your state board licensing material what is true for your state and if your client happens to be in a different state, what is true for that state? There are a few not many, I think it's two at this point at the time of this recording, two states that require you to be licensed both where your client is and where you are. So they consider therapy taking place in both of those places. That's not normal, but there are couple of states so you wanna check with that. So, no matter what and I imagine in some of your cases, your clients might be going to different places. So, for example, if you're at a University Counseling Center and the University closes down and your clients go back home with their family and their home is in another state, you're gonna be in the position of trying to figure this out. There are states that allow for a certain number of sessions in their state without you having to go through an application process. So it's worth checking that out. I can imagine that the boards are getting a magi-lion phone calls, so it might serve you to look on the website before you make that phone call just to try to help control the deluge that they're getting and to increase the likelihood of them being able to respond to questions that can't be answered on the website. So you just wanna check and make sure that you're abiding by the laws of where you are and where your client is so even if your state says, hey, we consider therapy where the therapist is, but your client is in another state. You still have to check out the laws of that state, too, and make sure that you're doing what they say as well. Okay, I know it's not super fun to read the legalities of this stuff, but it is really important and it's especially worth your time so that you're prepared in case an emergency does go down that you know who to call and how to facilitate emergency care for one of your clients and no matter how well we might assess our peeps before they come into our telehealth practice, life changes, situations changes and you might be dealing with somebody who's in a crisis and you wanna be really well prepared for that. Okay. So we've covered the fact that you need informed consent that addresses telehealth specifically and one of the pieces of how you address telehealth specifically is making sure that you have stated an emergency crisis response plan and all I mean by that, so that's not fancy at all, I mean by that is that you have looked at the state where the client is and what you need to do in case of an emergency and you've outlined that in your paperwork and you've covered when you would break confidentiality, according to that state's laws. So again, this sounds like a pain in the butt, it literally will take you two hours, just read through it, add it into your informed consent. And for liability providers that cover telehealth, you almost always get a free lawyer consult so you can use that to submit your informed consent to them and have them look it over so that you can feel really comfortable with it when you provide it to clients. Okay. Covered informed consent .We've covered emergency and crisis stuff. We've covered liability. Remember that, in my opinion, even if you don't think you're a HIPPA covered entity, I think you should function as one because if you were to ever get in trouble, they're gonna be comparing you against what would most therapist do in your situation and most therapists are HIPPA covered entities, so in that vein you want your informed consent to reflect that, again, you can get a shortcut on my website. It's that when you put the things into place that you need to actually deliver video therapy, you wanna make sure that those things are super secure and that they are HIPPA compliant, they're HIPPA level secure. So let's look at that. You're gonna need video if you're gonna be doing video sessions. Skype, FaceTime NOT HIPPA compliant. You are gonna need a software that's specifically listed as HIPPA compliant and they're willing to provide you a documentation called a BAA. A BAA is a business associates agreement and it is basically a company saying hey, even though legally we don't have to be HIPPA compliant. we're agreeing to be HIPPA compliant and to carry some of the liability associated with that if we screw up. So we definitely want somebody who's willing to engage in that contract with us. So when we think about video and we think about all the other things that you're gonna need, so HIPPA compliant email, HIPPA compliant video, HIPPA compliant way to bill or invoice your clients and to receive payment, a means of keeping records in a HIPPA compliant way. All of those little details, you can think about getting them in one of two ways you can get them through a package. so somebody's already bundled together all of the things that you need. My favorite package for that is through iTherapy. So it's I, I'm gonna do it in sign language for you, iTherapy.com and they have bundles of all the things that you could need. You can get it all in one place altogether. They've already got the BAA's with everybody and they can get you set up really quickly. They're a small, family owned business, and their customer service is second to none. I love them. So you can get it bundled and you can get all the pieces that you need in one place or you can piece meal it together. And when somebody wants to piece meal together, then they're in one of two camps. There's somebody who wants a lot of control over the particular software that they're going to use or they wanna get the best deal possible and spend the least amount of money. So if you're in a rush and you don't have a whole lot of change to be spending on this, then I'm gonna recommend that you piece meal it, but know that that's gonna be more effort for you to find the software that you want. I am gonna make a couple of recommendations, tho. So for a HIPPA clcompliant video software, you can get a program called Doxy.me for free. It's HIPPA compliant video and my experience with Doxy is that, depending on where you are and where your client is, it can be a perfect video connection or cannot be, The the most full-proof video that I have used is through Zoom and remember that you can get some of these pieces of software in versions that are HIPPA compliant and are not, so you wanna make sure that you're getting the HIPPA compliant one and the way that you confirm that is that they give you a BAA with it .So all that is a piece of paper. It's already written, you're not having to create anything, just say I need the BAA, thank you, and they will send it to you, if they're HIPPA compliant. So one way that you can get Zoom for free is to go through a company called Regroup Connect. I think it's Regroup.Connect. I haven't used them personally, but I know a lot of people who have. I think it's like Regroup/Connect and they have a version of zoom that, my understanding is HIPPA compliant, and they offer BAA and it's free. Don't hold me to this y'all! I don't know what's true five minutes from now in the telehealth world. Things are always changing but I think that's true. Then you're also going to want to get email that is HIPPA compliant. And kind of the the gold standard there is probably Hushmail, maybe Proton mail. I'm trying to think if there are any others off the top of my head. Those are the two that come to mind first and you're going to have a method of receiving payment that is secure and so if your piece mailing together, you might choose to use SquareUp. IVY Pay is another option. I know that there's another really commonly used one, but I'm forgetting what it is, but again remember that you need to get the BAA with it and I wanna give you a caveat about some of these pieces of software. So your practice is not HIPPA compliant just because you have bought products that are HIPPA compliant. HIPPA compliance is a process. And so here's a good example: With SquareUp, they give me, I have used them, they give me a BAA and that's saying, hey, yo we keep all your stuff secure and I'm great, thank you, I appreciate it. But I have to make choices about how I use it, and if I make certain choices, I have made it not secure. So here's an example of that. HIPPA is meant to protect electronic communication and to not put our clients at risk because we choose the convenience of electronic communication of protected health information, like their name and any related health stuff. The fact that they're in therapy is health information. Their email address is identifiable information. You put those two things together and now we have a breach, so HIPPA is like no breaches please and clients began complaining because they're like listen, I want my freaking medical records and I'm okay with the risk, send them to me in email. I don't wanna have to come by the office. Things like that. So HIPPA said, Okay, Okay. We hear you and we're going to create something called the Omnibus rule, and that rule covers lots and lots of things. but one of the things that it says is so long as you are offering to people a HIPPA compliant baseline, they can choose to opt into, listen carefully to that language. opt into features that are not HIPPA compliant. So with my clients, they're set up so that they can pay automatically through my software. So if I'm gonna send an invoice or provide a receipt, usually that's gonna come through email or text messaging right and I can't say that that's the way that I do things as my baseline because that's not HIPPA compliant. However, almost all my clients would like to get an invoice and a receipt and so they just check a box on my informed consent and put their initials on there to say, like I understand the risks, I understand I don't have to do this, I am opting in to do it anyway, so that's what the Omnibus rule allows us to do, among other things, but please remember that you have to have a way to do all of your practice, HIPPA compliantly and that it is an opt in, not an opt out. It's a choice that they're making and it can't be the only way that you offer to do things for your business to be HIPPA compliant. Okay. So we've covered video. We've covered some options for email. We've covered some options for getting payment. Health records, you are able to keep those on your computer, if you can keep your computer secure and you can check out Person-centered Tech website to know more about exactly how to keep your records secure on your computer. There are ways to keep them secure in the cloud. For example, you could use G-Suite, not just your Google Drive, but G Suite, which is an upgrade and comes with a BAA and a workbook with how to make sure that your cloud account is secure. Or, you could get a service like Theranest or Simple Practice. iTherapy obviously has all the stuff bundled together, so you don't have to make those choices and most of these electronic health record software systems will allow you to bill through them so you don't have to have an add on and many of them will allow you to bill through your insurance companies as well if you want that. Okay, those also have a really cool feature, usually they have a client portal. So you're able to put your paperwork in there and your clients can log in, fill it out, leave it in the portal for you, so it's never out in the world floating around unsecure. I really like portals for that feature if you are sending and receiving paperwork, but you don't have a portal, you do need to be pretty thoughtful about having a baseline of how you can do that in a HIPPA compliant way and then if they want an easier option, like for example, if they wanna receive it and give it back to you in email, but that is an opt in because even if your email is HIPPA compliant, it's HIPPA compliant while it's in your email, but it's floating out there in the world and while it's floating out there in the world to land in their email, it's not necessarily secure unless you have a version that encrypts it and you have a password, blah blah blah. That's why you want Hushmail. And then when it lands in their email, unless they have a HIPPA compliant email, which most of them won't have, it's not secure once it's there. So they're really kind of three places where it needs to be secure and that's one reason I really like a portal because it's secure in all the places. Hushmail does have an opportunity for you to secure while it's in Hushmail, it can be encrypted and password protected so that it lands over there in a secure way, and then if they would like to, if it's important to them, they can also purchase their own version of Hushmail so that when they receive it and it's on their computer, it remains secure. So there are lots of ways to do this, but I imagine as you're listening to all that you're like, please just give me the package, like that's a lot to think about. That's definitely where I landed and I love that the package that I have uses all of the software I would have picked on my own anyway. So it's a win win for me. Okay, so we've covered software. There are text messaging products that you can get that are HIPPA compliant as well. There's one called Signal that's free and your client can get the app on their phone. You can have the app on your phone. You can both also have it on your laptop and it's so secure that, according to Roy, at Person Centered Tech, it doesn't even require a BAA because it's that level secure. So that's an option as well. Again like nobody is as careful about your license as you are, so these are all just tips and tricks, but I want you to make sure that you are looking at your licensure requirements, looking at your code of ethics because remember they vary so much by profession and our state laws vary so much, even in the same state by profession, it's crazy, but make sure that you're covering yourself and your clients. Okay. Upgraded paperwork, we got that. Liability insurance, we've got that. We've covered the products that you need. I hope I'm not forgetting anything. I don't think that I am. I'll add it in the comments if I have. You might be wondering, do you need specialized training to provide telehealth? I've made a podcast about this. I will link it somewhere in here. I personally think that you should do some training just to make sure that you know what the heck you're doing, but whether you have to or not depends on a few places. So check first with your liability insurance. Do they require you to, and if so, that's gonna come in one of two formats. Either they're gonna say, like, one of three, we just wanna see demonstration that you have done some telehealth education so that might be through my course, it might be through a CEU course, that might be through a certification program, but they might just leave it open ended. Another option would be that they say you need a certain number of CEUs and have that documented. Another might say we need to see you having gone through a certification process. My guess is that in the state of Corona virus situation that we're dealing with, that you could probably get a pause on that requirement from your board If you email them and explain the situation, but that's just my take. I would email them and find out. Most States do not require certification. Most ethics bodies don't require certification. Most liability insurances don't require certification. If you are paneled with an insurance company, some of them will require certification and through a particular company and might even require you to use a particular platform to deliver services. So if you're doing this through insurance, then you wanna check that out with the insurance company. Okay. So we're gonna check with our liability provider. We're going to check if you are paneled by insurance companies and you plan on delivering telehealth and have it billed through insurance. You're going to check with your state board if they require anything and most of the time what I'm seeing is that they leave it open and say something like, you know you need to be competent in all of the services that you provide and can demonstrate your competence. Some of them are requiring a certain number of CEUs. Usually it's a low number. Very few are requiring certification or a high number of CEUs. So liability insurance insurance, insurance if you are paneled, your state board and your professional code of ethics. So that's the last place, your professional code of ethics. I really think it's important to have community when you're doing something new and so you are very welcome to join my Free Facebook group, it's Online Therapist Group. We answer tons of questions in there and provide support for one another, so it's free, we got you. There are a lot of people in there who've been doing telehealth for a long time and can provide you any support that you need. Okay. So you don't have to be out there all by yourself trying to figure this out. I know I just gave you a lot of information pretty quickly. I just wanna give you a few clinical tips and then I'm gonna wrap up and know that you can always reach out and I give you as much information as I can okay. So tip number one. You want to be making eye contact with your clients and as therapists we get a lot of information from the queues on our clients' faces, right? So what I don't want you to do is stare at the camera. So this is me looking at myself in the video as I'm filming it and it should look to you like I'm looking you pretty close in the eye. This is me looking at the camera. It should look weird. It should look like I'm not looking at you anymore. So what I like to do when I have my clients in session is instead of having the screen full size out to the edges. I minimize it so that it's, I don't know like two thirds the size the screen, and I push it up underneath the video button, the video camera, and that way when I look them in the eyes, it just happens to be the sweet spot that looks like I'm looking them in the eyes and so I can read all of their queues and they can do the same with me and I coach them in the early sessions to do this so that we're making eye contact and let me tell you it makes a huge difference in a clinical work, like a huge difference, and they may not be used to that if they've been Skyping or FaceTiming or whatever with friends and family, so I do make sure I train them on like hey, this is super important. We really wanna make sure that we're doing this and if it feels like I'm not looking at you, you need to tell me so that we can fix that up. So eye contact really really matters. Most states will want you to know the physical address, and I just think it's a good idea, to know the physical address where your client is at the time of service so that if they go into like a medical emergency or psychological emergency, you can get them help to where they are. And so with all of my clients, I get the address where they're going to be doing therapy. And you guys will start to notice like it's the same background they're at the same place. You won't need to ask every single time, but you wanna know where the heck they are and if it looks different in the background to make sure that you have the new address. If they happen to be in their car during therapy, you can just have them go on Google Maps, hold the button down for where they are, and then share that location with you via your HIPPA compliant phone. They can just text it to you and then you'll know exactly where they are even if they don't know the address. So really good eye contact, making sure you know where they are in case of an emergency, and then there are some things about, you know the less nervous you are, the less awkward it's gonna feel for them. So practice with a friend or two before you start providing sessions to someone because it can just feel really awkward the first few times and the more you can normalize, like listen, we're gonna get disrupted sometimes, like I'm gonna hear your kid in the other room. You might hear my dog bark. Just like if we're in an office together and sometimes you're gonna be able to hear the therapy client next door crying or sometimes you're gonna hear somebody in the break room laughing really loudly. It's a same thing, so it might feel weird because we're doing telehealth and that feels novel, but those kinds of distractions are pretty normal, no matter where we happen to be. And I usually will tell them the story about having worked in a counseling center and we constantly had fire alarms going off and like, listen nothing that can happen at your house or my house is gonna be as distracting as that was. The other thing is that because it's online, for some people because they're used to Skyping or FaceTiming with their friends, it can feel naturally more casual to them. and so I often will set the frame in the first session or two about that. And I'll say like sometimes what we find with telehealth is that people are able to go deeper and faster because they are in their comfort place. They're in their home. They've got their favorite blanket with them. They've got their own box of tissues. You know, maybe they've journaled just before and can journal after. There are a lot of benefits to you being in your own space, but also sometimes it's so comfortable that we forget some things, so just as a reminder, therapy is a sacred space. We don't bring glasses of wine or other alcohol into session. We don't bring other people into session, like it needs to be a private place, and we need to make sure that you're going to be able to block out this time so that you're not interrupted. So if you've got kids at home that somebody else is taking care of them, all of that good stuff, because this is an important time and we wanna protect it. That's worked just fine. I think a lot of the fears that people have about telehealth, when you really think them through, don't make any sense. So if your head is like but what would I do if they're lying about their location? I just want you to think for a minute about in a physical practice when you get your client's address, how often does it go through your head of, is this their real address? Maybe it's not. It doesn't. Same with your online practice. It would be really odd for somebody to give you the wrong address. Right? Like we don't go to our clients' houses and confirm that that's their address. We don't get on Google Maps and confirm oh yeah that's their car, I saw it in the the parking lot. So some of the things that we're afraid of, if you just think for a minute of like, okay, what's a correlate in my in-person practice, and does this fear really make sense when I compare the two? I think you're gonna feel a lot better. The same thing comes up around like what if a crisis happens? What if my client becomes suicidal or at risk for hurting somebody else? And I would say we'll okay, so what would you do in your physical practice? And when people give me the steps that they would take in their physical practice, they never ever include tackling the client. They never include grabbing the client restraining them. So there's nothing extra that you'll be doing online that you would not be doing in person like we're not gonna physically restrain our clients, so even though it feels different, think through the steps and then think through like okay, well, yeah, that would be exactly what I would do online. And if there's anything a little different, then you just need to think through what to do. So, for example, I worked at a University Counseling Center and part of our crisis response was to use the local mobile crisis response unit if somebody called us after hours in emergency. Not every county has one of those. So if I have a client that's in a different county, I just need to think through, okay so what does that county have and how would we use that? And I think that through in the very beginning and I talk with the client about it in the very first session, so we just have a plan together and then if drama happens, I know what I'm supposed to be doing. So it's just kinda thinking that stuff through and if you hit some roadblocks, we have hit them too. So you can just come on in and ask us on in the Online Therapist Group and we will help you. We'll help you work it through. It's a really great group of people, super helpful, super generous. If you have questions that are not addressed here, I think I'm going to put this maybe on YouTube and maybe on my Facebook Page. Just drop questions over there, I'm happy to answer them for you. I also have a "Get It Going Checklist" that has all of these things in there as well as links to some of the harder to find information. So if you're like, I don't know where the heck my legal codes are for my state, we've got links to most of that in the "Get It Going Checklist" and that's a free checklist. If you're like, what software did you say again? We've got all that in the checklist as well. Okay, I hope that was helpful. I know that y'all are probably super stressed about the idea that you might be moving Into telehealth during this phase of, I don't wanna call it a crisis cuz I'm not gonna I'm not gonna feed into that kind of energy, during this opportunity for us to learn a new way of connecting and supporting our people. I hope this was helpful you guys. Please let me know if you have any other questions. Have a really great day.