Healthcare Telepsychology Form

HEALTHCARE TELEPSYCHOLOGY FORM

Patient Information

Patient Name:    Date of Birth:    Gender:

Insurance Information

Medical & Mental Health History

Current medications (prescription and over-the-counter):

Allergies (medication, food, environmental):

Prior surgeries or hospitalizations (include dates):

Current mental health diagnoses or concerns:

Have you had thoughts of harming yourself or others in the past year?    Yes    No

Telepsychology Services — Nature & Consent

Description of telepsychology services: The clinician will provide mental health evaluation, psychotherapy, consultation, and treatment planning using secure audio-visual technology. Telepsychology sessions will be conducted remotely and may include interactive communication, assessment, and clinical documentation.

Risks and benefits: I understand that telepsychology has benefits such as increased access and convenience, and risks such as potential technology failure, breaches of confidentiality despite reasonable safeguards, and limitations for certain assessments. I have had an opportunity to discuss alternatives including in-person services and refuse telepsychology services.

Technology and privacy: I understand I am responsible for using a private, secure location and for my device and internet connection. I consent to the clinician's use of electronic communication and technology for sessions and clinical records. I acknowledge that absolute confidentiality cannot be guaranteed in electronic transmissions.

Emergency procedures: Telepsychology is NOT appropriate for psychiatric emergencies. I will provide the physical address where I will be located at the time of each telepsychology session and a local emergency contact. If I am in immediate danger, I will call local emergency services. If the clinician believes I am at imminent risk of harm, the clinician may initiate emergency procedures in my local area.

Consent Options & Acknowledgments

I authorize the use of telepsychology for my mental health care and acknowledge the following (check each that you agree to):

I consent to electronic communication (email, text) for appointment information and clinical matters, understanding associated privacy risks.
I consent to audio and/or video recording of sessions when clinically indicated and only with my explicit permission for each recording.
I consent to the secure sharing of relevant clinical information with my insurance carrier and other designated providers for treatment and billing purposes.
I acknowledge the clinician's telepsychology platform has reasonable security measures, and I agree to use the platform in accordance with instructions.

Fees and cancellation: I understand standard session fees, co-pays, and applicable insurance billing may apply. Cancellation policy requires advance notice; late cancellations or missed sessions may be billed. I understand billing and payment policies will be provided separately.

Ability to withdraw: I may withdraw consent to telepsychology at any time by notifying the clinician. Withdrawal does not affect disclosures or actions already taken based on prior consent.

Legal Certifications & Patient Attestation

By signing below I certify that I have read and understand this Healthcare Telepsychology Form, that I have had the opportunity to ask questions and receive answers about telepsychology, its risks and benefits, and alternatives, and that I consent to remote mental health services as described. I attest that the information I have provided on this form is true and accurate to the best of my knowledge.

I understand the clinician will document clinical information in my medical record and that such records may be disclosed as required by law or as authorized by me in writing. I further understand that telepsychology may be limited by technology and that the clinician may determine telepsychology is not clinically appropriate and recommend in-person care.

Patient initials to acknowledge receipt of privacy notice and telepsychology information:   

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