Telehealth Phone Session Consent Form

Bird & Associates Psychological Services are pleased to offer our clients Telehealth sessions during times of need. The providers that our practice currently uses are Jane and/or Doxy. Jane and/or Doxy are confidential HIPPA and GDPR compliant platforms that protect clients’ information and confidentiality.

It's important to note that despite Jane and/or Doxy being convenient platforms, it's essential that you are aware of the risks and limitations if you choose to utilize this service. Telehealth isn't always safe and practical to use with everyone. Please speak with your individual clinician to determine if it's right for you.

If you proceed, please be aware of the following risks:
1. The video or call quality may not always be the best. At times, the connection may get disrupted. The clinician may ask you to repeat yourself. It's important at the beginning of the session that the clinician is aware of your location and that you provide them with a number that they can reach you at if the
connection gets dropped.

2. It's more difficult for clinicians to read clients non-verbal cues and body language over a video call. This may result in the clinician having to ask you to describe your thoughts and feelings in greater detail as you would if you were attending a face to face appointment.

3. The clinician can make every attempt to secure the environment that they're working out of remotely, however, they can't control the level of confidentiality and protection in the client's environment. We recommended that you designate a private room and wear headphones in order to maximize privacy.

4. It's important to note that the same limits of confidentiality apply through Telehealth as it does in face to face sessions. For example, if the clinician believes that you are at an imminent risk of hurting yourself or others, then 911 will be called to your location to ensure safety.

Logistics:
When the clinician provides phone/video-counseling sessions, They will call you at our scheduled time or send you a link for our secure and HIPAA compliant video session. Your clinician will expect that you are available at your scheduled time and be prepared, focused and engaged in the session. The clinician will be calling you from a private location where they will be the only person in the room. You also need to be in a private location where you can speak openly without being overheard or interrupted by others, in order to protect your own confidentiality. If you choose to be in a place where there are people or others can hear you, your clinicians are not responsible for protecting your confidentiality. Every effort MUST be made on your part to protect your own confidentiality. We suggest you wear a headset to increase confidentiality and also improve the sound quality of our sessions. Please know that we cannot guarantee the privacy or confidentiality of conversations held via phone, as phone conversations can be intercepted either accidentally or intentionally. Please ensure you reduce all possibilities of interruptions for the duration of our scheduled appointment.

Please know that per best practices and ethical guidelines, clinicians can only practice in the Province that we are licensed in. That means that the clinician must be licensed wherever you reside. There are some special circumstances, and your clinician can notify the regulatory Board in other Atlantic provinces to seek permission to practice in their jurisdiction temporarily while you are residing in their province. Please agree to inform the clinician if your therapy location has changed or if you have relocated to a province outside Nova Scotia.

Connection Loss During Phone Sessions: If you lose phone connection during your session, your clinician will call you back immediately. If we are unable to reach each other due to technological issues, your clinician will attempt to call you 3 times. If they cannot reach you, they will remain available to you during the entire course of your scheduled session. If the reason for a connection loss i.e. technology, your phone battery dying, bad reception, etc. occurs on your part, you will still be charged for the entire session. If the loss for connection is a result of something on our end, your clinician will call you from an alternate number. The number may show up as restricted or blocked, so please be sure to pick it up.

Connection Loss During Video Sessions: If we lose our connection during a video session, Your clinician will call you to troubleshoot the reason we lost connection. If your clinician cannot reach you, they will
remain available to you during the entire course of our scheduled session. If the reason for a connection loss i.e. technology, battery dying, bad reception, etc. occurs on your part, you will still be charged for the entire session. If the loss for connection is a result of something on our end, we can either complete our session via phone, or plan an alternate time to complete the remaining minutes of our session.

Recording of Sessions:
Please note that recording, screenshots, etc. of any kind of any session is not permitted and are grounds for termination of the client-therapist relationship.

Payment for Services:
Payments for services must be made prior to each session. Our receptionist will charge your card on file or send you an invoice. Payment is to be completed prior to our session.

Cancellation Policy:
If you must cancel or reschedule an appointment, 24-hour advance notice is required, otherwise you will be held financially responsible. Should you cancel or miss an appointment with notification less than 24 hours this will result in being charged the full fee for your missed appointment. If clients have more than 2 cancellations during the course of treatment/therapy the therapist and client will address the need for ongoing therapy. Should a client express and wish and/or desire to continue, a client may be asked to pre-pay for sessions when they are scheduled. If the client cancels or misses the session with less than 24 hours notice and the session is pre-paid, this follows the cancelation guidelines and the payment will not be reimbursed for the missed or canceled session less than 24 hours. Phone/video sessions should be treated as regular in-office sessions. If you are late getting on the phone, are unable to talk at our scheduled time, your battery has died and you are unable to access another confidential place to talk, or
any other variable that would have you not be able to attend our session, please know that you will be charged for the session. Please make the necessary arrangements you need to be available and present for your session.

    Please list your main number and an alternate number below:

    Emergencies and Confidentiality:
    I request an emergency contact for you. Please list the person’s first and last name, relationship and phone number(s) of your emergency contact:

    I also request the address from which you are calling and the number to your local police department, including area code, for the area in which you are located during the time of our call.

    If a situation occurs where we are talking and get disconnected and you are in crisis, you agree to call 911, go to your local emergency room immediately or contact the National Suicide Hotline at 800-784-2433.

    If your clinician has concerns about your safety at any time during a phone session, They will need to break confidentiality and call 911 (if located in the same county or emergency services in the area you are located at the time of the call) and/or your emergency contact immediately. Please note that everything in our informed consent that you signed, including all the confidentiality exceptions, still applies during phone/video sessions.


    Consent to Participate in Telehealth Sessions through Physitrack:

    Please complete the applicable consents below.

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