Consent Form
Thank you for completing the intake questionnaire. Next, please review the consent form below in its entirety before signing it.
Informed Consent Form
This Informed Consent for Telehealth contains important information focusing on providing healthcare services using the phone or the Internet. Please read this carefully, and let me know if you have any questions. When you sign this document, it will represent an agreement between us.
Benefits and Risks of Telehealth: Telehealth refers to providing psychological services remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of telehealth is that the patient and clinician can engage in services without being in the same physical location. This can be helpful particularly when the patient and clinician are in different locations or are otherwise unable to continue to meet in person. It is also more convenient and takes less time. Telehealth, however, requires technical competence on both our parts to be helpful. Although there are benefits of telehealth, there are some differences between in-person treatment and telehealth, as well as some risks. For example:
Risks to confidentiality: As telehealth sessions take place outside of a psychologist’s office, there is potential for other people to overhear sessions if you are not in a private place during the appointment. On my end, I will take reasonable steps to ensure your privacy. It is important; however, for you to make sure you find a private place for our appointment where you will not be interrupted. It is also important for you to protect the privacy of our appointment on your cell phone or another device. You should participate in the consultation only while in a room or area where other people are not present and cannot overhear the conversation.
Issues related to technology: There are many ways that technology issues might impact telehealth. For example, technology may stop working during a session, other people might be able to get access to our private conversations, or stored data could be accessed by unauthorized people or companies.
Crisis management and intervention: Usually, I will not engage in telehealth with clients who are currently in a crisis situation requiring high levels of support and intervention. We may not have an option of in-person services presently, but you may require a higher level of services in a crisis situation. Before engaging in telehealth, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our telehealth work.
Electronic Communications: You may have to have certain computer or cell phone systems to use telepsychology services. You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software to take part in telehealth. For communication outside of appointments, I only use email communication and only for administrative purposes unless we have made another agreement. This means that email exchanges should be limited to administrative matters. This includes things like setting and changing appointments, billing matters, and other related issues. You should be aware that I cannot guarantee the confidentiality of any information communicated by email. Therefore, I will not discuss any clinical information by email and prefer that you do not either. Also, I do not regularly check my email and do not respond immediately, therefore, this method should not be used if there is an emergency.
Confidentiality: I have a legal and ethical responsibility to make my best efforts to protect all communications that are a part of telehealth services. The nature of electronic communications technologies, however, is such that I cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. I will try to use updated encryption methods, firewalls, and backup systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for telehealth sessions and having passwords to protect the device you use for telehealth). Limits to confidentiality still apply in telehealth. Although there may be some variability from state to state, any immediate risk of harm to you or another person may require the need to break confidence in an effort to keep you or someone else safe. Additionally, I am a mandated reporter for suspected child abuse. Finally, although rare, I must comply with a court order that asks for the release of your records. Please let me know if you have any questions about exceptions to confidentiality.
Emergencies and Technology: Assessing and evaluating threats and other emergencies can be more difficult when conducting telehealth than in traditional in-person treatment. To address some of these difficulties, we will create an emergency plan before engaging in telehealth services. I will ask you to identify an emergency contact person who is near your location and who I will contact in the event of a crisis or emergency to assist in addressing the situation. If the session is interrupted for any reason, such as technological connection failure, and you are having an emergency, do not call me back; instead, call 9-8-8 (national suicide hotline), 9-1-1, or go to your nearest emergency room. Call me back after you have called or obtained emergency services. If the session is interrupted and you are not having an emergency, disconnect from the session and then re-connect via the telehealth platform on which we agreed to use. If I do not connect via the telehealth platform within two (2) minutes after this disruption, then call me at 484-477-6378. Also if you are having trouble joining your appointment, please call or text me at the number above.
Fees: The fee for the presurgical evaluation is $249. Typically, this is a one-time appointment, but there are times when a brief follow-up appointment is needed prior to surgery. If this should happen, there will be no additional charge for this follow-up visit. There is a $50 deposit required to schedule your evaluation. The remaining $199 will be due on the day of your appointment no later than 30 minutes before the start of your appointment. If payment has not been received by the scheduled appointment time, you will be given the opportunity to make a payment before the evaluation begins (online or by phone). In the event of a missed appointment, the $50 deposit will be forfeited. If the balance due is not paid at the start of the appointment, and you are unable to make a payment at this time the evaluation will not proceed and you will forfeit the $50 deposit. If you cancel an appointment more than 24 hours prior to the start of your appointment, you are eligible for a full refund of any payments made. If you cancel your appointment within 24 hours of the start time you are eligible for a refund of any payment made with the exception of the initial $50 deposit. I do not accept insurance, however, you may be eligible for reimbursement if your plan has out-of-network benefits. Upon request, you will be provided with the necessary information to seek reimbursement from your insurance. Insurance or other managed care providers may not cover sessions conducted via telecommunication. Additionally, not all plans have out-of-network benefits. Please contact your insurance company prior to our engaging in telehealth sessions in order to determine whether this evaluation will be covered.
Records: The telehealth sessions shall not be recorded in any way unless agreed to in writing by mutual consent. I will maintain a record (written report) of our session(s) in the same way I maintain records of in-person sessions in accordance with my policies. The evaluation report will be sent to your surgeon via fax upon receipt of payment in full. You will need to provide the name, address, and fax number of your surgeon prior to our appointment.
Qualifications: I am a licensed psychologist in the state of Pennsylvania. I also have the Authority to Practice Interjurisdictional Telepsychology (APIT) and E. Passport through The Psychology Interjurisdictional Compact (PSYPACT). PSYPACT is an interstate compact designed to facilitate the practice of telepsychology across state boundaries. To provide services to you, your state must be a participating state with PSYPACT.
Dennis Given, Psy.D.
Licensed Psychologist
PA License #PS016275
APIT / E. Passport Mobility #6589