This Informed Consent for Telepsychology has important information about psychotherapy via phone or the Internet. Please note that Champion Psychological Services, LLC (henceforth abbreviated as CPS, LLC) offers telepsychology sessions.

Benefits and Risks of Telepsychology

Telepsychology refers to psychotherapy services that are provided remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of telepsychology is that the client and clinician can engage in services without being in the same physical location. Telepsychology, however, requires some technical competence on both our parts to be helpful.

Although there are benefits to telepsychology, there are some differences between in-person psychotherapy and telepsychology, as well as some risks. For example:

• Risks to confidentiality. Because telepsychology sessions take place outside the therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. CPS, LLC will ensure the therapist’s privacy. But it is important for you to make sure you find a private place for the session where you are so that you will not be interrupted and can protect the privacy of the session on your cell phone or other device. You should participate in therapy only while in a room, or area where other people are not present, and cannot overhear the conversation.

• Issues related to technology. Technological issues can impact telepsychology. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people, or companies The latter may occur if CPS is not using a HIPAA-compliant technology service provider, such as Face Time or a telephone. CPS, LLC currently uses HIPAA-compliant Therapynotes.

Champion Psychological Services, LLC (CPS, LLC)

• Crisis management and intervention. CPS, LLC recognizes that telepsychology is not an appropriate intervention for crisis management. If you are in crisis, you may certainly call CPS, LLC and we will determine what is clinically appropriate, including referral to your nearest emergency room, Crisis Center, or a call to 911. However, please be aware, CPS, LLC staff are not available 24 hours per day/ 7 days per week. CPS, LLC staff will return your call as soon as possible.

Electronic Communications

You may need certain computer, or cell phone systems to use telepsychology services. You are solely responsible for any cost to you to obtain necessary equipment, accessories, or software to take part in telepsychology.

Confidentiality

CPS, LLC has a legal, and ethical responsibility to make best efforts to protect all communications that are a part of telepsychology. However, the nature of electronic communications technologies is such that it cannot guarantee that communications will be kept confidential, or that other people may not gain access to these communications. As with any electronic communication, there is an inherent risk that electronic communications may be compromised, unsecured, or accessed by others.

You should also take reasonable steps to ensure the security of communications (for example, using only secure networks for telepsychology sessions and having passwords to protect the device you use for telepsychology).

Please do not share the password you use for telepsychology.

If you are having a psychological emergency, you may call CPS LLC staff at (609) 638-7560 if you need to speak with staff, leave a message. If staff are unable to pick up the phone when you call, CPS LLC staff will get back to you as soon as possible. If there is an emergency, please contact /go the nearest hospital immediately. Please note, staff are not available 24 hours per day, or 7 days per week. Assessing and evaluating threats and other emergencies can be more difficult when conducting telepsychology than in traditional in-person therapy. To address some of these difficulties, CPS, LLC staff will create an emergency plan before engaging in telepsychology services. CPS LLC staff ask you to identify an emergency contact person who is near your location whom CPS, LLC staff will contact in the event of a crisis or emergency to assist in addressing the situation. By signing this form, you are allowing staff to contact your emergency contact person as needed during such a crisis or emergency.