child psychologist

Renee Goosen Psychology Telehealth Consent Form

  • Terms and Conditions and Consent

  • 1. Consent to Engage in Online Treatment - Where it is required, a video, telephone or online (telehealth) consultation may be offered. The telehealth platform used in this practice is Zoom. It is an online video conferencing system. The privacy of any form of communication via the internet is potentially vulnerable and limited by the security of the technology used.

    2. In addition to the consent to treatment already signed, I understand the following: I am responsible for the costs associated with setting up the technology needed so I can access telehealth services. Renee Goosen Psychology will be responsible for the cost of the call to you and the cost associated with the platform used to conduct telehealth services.

    3. The purpose of the psychological therapy session is for you, the client, for therapy use only, and use of video or audio recording is not permitted to be used for any other purposes, including providing the recording to anyone else in person or on social media. To access telehealth consultations I will need access to a quiet, private space; and the appropriate device, i.e. smartphone, laptop, iPad, computer, with a camera, microphone and speakers; and a reliable broadband internet connection.

    3. Limitations of telehealth - A telehealth consultation may be subject to limitations such as an unstable network connection which may affect the quality of the psychology session. In addition, there may be some services for which telehealth is not appropriate or effective.

    4. Fees - The cost of a consultation (approximately “50” minutes) is $190.00, which is payable at the end of the session by credit card to be provided and stored in our secure Halaxy payment system. Your psychologist will discuss with you your eligibility for Medicare or other compensable funding.

    5. Consent to receive psychological services by telehealth - I have been provided with information about the service including the limitations to privacy and confidentiality and I have agreed that in circumstances where the psychologist is concerned about my welfare and is unable to contact me, permission is provided for the psychologist to contact my emergency contact person provided in my claiming and consent form.

    6. I have read and understood the information in this Consent Form and have discussed any outstanding questions with the practice/psychologist. I agree to the above conditions for telehealth psychological services to be provided by Renee Goosen.