Teletherapy consent forms & Privacy Statement (Minor)

in teletherapy with Bronwyn Russo Clinical Psychologist. Teletherapy is a form of psychological service provided via internet technology, which can include consultation, treatment, transfer of medical data, emails, telephone conversations and/or education using interactive audio, video, or data communications. I also understand that teletherapy involves the communication of my medical/ mental health information, both orally and/or visually.

Teletherapy has the same purpose or intention as psychotherapy or psychological treatment sessions that are conducted in person. However, due to the nature of the technology used, I understand that teletherapy may be experienced somewhat differently than face-to-face treatment sessions.

I understand that I have the following rights with respect to teletherapy. I also understand that any references to ‘I’ or first person pronouns in this consent form, applies to myself as the parent/ guardian as well as to my child:

Client’s Rights, Risks, and Responsibilities:
1) I, the client, have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.

2) The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy or consultation is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, which are as follows:

All personal information gathered during the provision of psychological service will remain confidential and secure except when:
i. It is subpoenaed by a court; or
ii. Failure to disclose the information would place you or another person at risk; or
iii. Your prior approval has been obtained to:
a) provide a written report to another professional or agency e.g. a GP or another professional; or
b) discuss the material with another person e.g. a family member

Generally files are kept for a minimum of five years then destroyed.
3) I understand that there are risks and consequences of participating in teletherapy, including, but not limited to, the possibility, despite best efforts to ensure high encryption and secure technology on the part of my psychologist, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission could be interrupted by unauthorized persons; and or electronic storage of my medical information could be accessed by unauthorized persons.

4) There is a risk that services could be disrupted or distorted by unforeseen technical problems.

5) In addition, I understand that teletherapy based services and care may not be as complete as face-to-face services. I also understand that if my psychologist believes I would be betterserved by another form of therapeutic services (e.g. face-to-face services) I will be referred to a professional who can provide such services in my area.

6) I understand that I may benefit from teletherapy, but that results cannot be guaranteed or
assured. I understand that there are potential risks and benefits associated with any form of psychotherapy.

7) I accept that teletherapy does not provide emergency services. If I am experiencing an
emergency situation, I understand that I can call the National Psychiatric Referral Hospital tel: 25055170 or proceed to the nearest hospital emergency room for help. Clients who are actively at risk of harm to self or others are not suitable for teletherapy services. If this is the case or becomes the case in future, my psychologist will recommend more appropriate services.

In case of emergency my location is (residential address):

Contact information for a local emergency contact is (Full name; relationship to client and contact details):

I understand the therapist may contact my emergency contact and/or appropriate authorities in case of emergency.

8) I understand that there is a risk of being overheard by anyone near me if I am not in a private room while participating in teletherapy. I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my teletherapy sessions, and (2) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session. It is the responsibility of the psychological treatment provider to do the same on their end.

9) I understand that dissemination of any personally identifiable images or information from the teletherapy interaction to researchers or other entities shall not occur without my written consent.

10) I understand that If I need to cancel or postpone the teletherapy appointment, I am required to give at least 24 hours notice, otherwise I will be charged in full for the missed session.

I have read, understand and agree to the information provided above regarding telehealth:

I have also read this consent form to my child for their understanding: