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Psychological Consultation and Therapy Services, PLLC Telemental Health Services Informed Consent

●Paul Gunser, Psy.D.

1 John Street

Millerton, NY 12546


❖You will need access to certain technological services and tools to engage in telehealth-based services with your provider

❖Telehealth has both benefits and risks, which you and your provider will be monitoring as you proceed with your work

❖It is possible that receiving services by telehealth will turn out to be inappropriate for you, and that you and your provider may have to cease work by Virtual Mental Health Services. You can stop work by Telehealth at any time without prejudice

❖You will need to participate in creating an appropriate space for your telehealth sessions

❖You will need to participate in making a plan for managing technology failures, mental health crises, and medical emergencies

❖Your provider follows security best practices and legal standards in order to protect your health care information, but you will also need to participate in maintaining your own security and privacy

What is Telemental Health?

“Telemental health” means, in short, ”provision of mental health services with the provider and recipient of services being in separate locations, and the services being delivered over electronic media.”

Services delivered via telehealth rely on a number of electronic, often Internet-based, technology tools. These tools can include videoconferencing software, email, text messaging, virtual environments, specialized mobile health (“mHealth”) apps, and others. We use Zoom Pro for confidential and HIPAA compliant communications as well as for encrypted emails.

➢You will need access to Internet service and technological tools needed to use the above-listed tools in order to engage in telehealth work with your provider.

➢If you have any questions or concerns about the above tools, please address them directly to your provider so you can discuss their risks, benefits, and specific application to your treatment.

Benefits and Risks of Telehealth

Receiving services via telehealth allows you to:

Receive services at times or in places where the service may not otherwise be available.

Receive services in a fashion that may be more convenient and less prone to delays than in-person meetings.

Receive services when you are unable to travel to the service provider’s office.

The unique characteristics of telemental health media may also help some people make improved progress on health goals that may not have been otherwise achievable without telemental health.

Receiving services via telemental health has the following risks:

Telemental health services can be impacted by technical failures, may introduce risks to your privacy, and may reduce your service provider’s ability to directly intervene in crises or emergencies. Here is a non-exhaustive list of examples:

Internet connections and cloud services could cease working or become too unstable to use

Cloud-based service personnel, IT assistants, and malicious actors (“hackers”) may have the ability to access your private information that is transmitted or stored in the process of telemental health-based service delivery.

Computer or smartphone hardware can have sudden failures or run out of power, or local power services can go out.

Interruptions may disrupt services at important moments, and your provider may be unable to reach you quickly or using the most effective tools. Your provider may also be unable to help you in-person.

There may be additional benefits and risks to telemental health services that arise from the lack of in-person contact or presence, the distance between you and your provider at the time of service, and the technological tools used to deliver services. Your provider will assess these potential benefits and risks, sometimes in collaboration with you, as your relationship progresses.

Assessing Telemental Health’s Fit For You

Although it is well validated by research, service delivery via telemental health is not a good fit for every person. Your provider will continuously assess if working via telemental health is appropriate for your case. If it is not appropriate, your provider will help you find in-person providers with whom to continue services.

Please talk to your provider if you find the telemental health media so difficult to use that it distracts from the services being provided, if the medium causes trouble focusing on your services, or if there are any other reasons why the telemental health medium seems to be causing problems in receiving services. Raising your questions or concerns will not, by itself, result in termination of services. Bringing your concerns to your provider is often a part of the process.

You also have a right to stop receiving services by telemental health at any time without prejudice. If your provider also provides services in-person and you are reasonably able to access the provider’s in-person services, you will not be prevented from accessing those services if you choose to stop using telemental health. However, in-person services are not expected for the foreseeable future.

Your Telemental Health Environment

You will be responsible for creating a safe and confidential space during sessions. You should use a space that is free of other people. It should also be difficult or impossible for people outside the space to see or hear your interactions with your provider during the session. If you are unsure of how to do this, please ask your provider for assistance.

Our Communication Plan

At our first session, we will develop a plan for backup communications in case of technology failures and a plan for responding to emergencies and mental health crises. In addition to those plans, your provider has the following policies regarding communications:

The best way to contact your provider between sessions is to call by telephone at 914-263-9023, or text at 914-263-9023.

Your provider will respond to your messages Please note that your provider may not respond at all on weekends or holidays. Your provider may also respond sooner than stated in this policy. That does not mean they will always respond that quickly.

Our work is done primarily during our appointed sessions, which will generally occur during day business time hours. Contact between sessions should be limited to:

Confirming or changing appointment times

Billing questions or issues

Scoring and report writing at an additional charge if tests were administered

Your provider is located in the EST time zone. Please note the time difference from your own time zone.

Please note that all textual messages you exchange with your provider, e.g. emails and text messages, will become a part of your health record.

Your provider may coordinate care with one or more of your other providers. Your provider will use reasonable care to ensure that those communications are secure and that they safeguard your privacy.

Our Safety and Emergency Plan

As a recipient of telemental health-based services, you will need to participate in ensuring your safety during mental health crises, medical emergencies, and sessions that you have with your provider.

Your provider will require you to designate an emergency contact. You will need to provide permission for your provider to communicate with this person about your care during emergencies.

Your provider will also develop with you a plan for what to do during mental health crises and emergencies, and a plan for how to keep your space safe during sessions. It is important that you engage with your provider in the creation of these plans and that you follow them when you need to.

Your Security and Privacy

Except where otherwise noted, your provider employs software and hardware tools that adhere to security best practices and applicable legal standards for the purposes of protecting your privacy and ensuring that records of your health care services are not lost or damaged.

As with all things in telemental health, however, you also have a role to play in maintaining your security. Please use reasonable security protocols to protect the privacy of your own health care information. For example: when communicating with your provider, use devices and service accounts that are protected by unique passwords that only you know. Also, use the secure tools that your provider has supplied for communications.


Please do not record video or audio sessions without your provider’s consent. Making recordings can quickly and easily compromise your privacy, and should be done so with great care. Your provider will not record video or audio sessions.

Please note that the fee for missed sessions is the charge that would have been paid by your insurance or if you are a self-pay client, the same fee as you usually pay. Extending circumstances may result in you not being responsible for the missed session. Otherwise, 24 hour cancellation is required to avoid fees. I also consent to my providers communicating with one another (Dr. Gunser) and my other doctors/healthcare providers. I enclose the name of that provider / or those providers here.

My consent to the above particular items as listed in hereby signed:

_________________________________________________ ________________________

Patient’s Signature Date


Patient’s printed name

The name and phone number of my healthcare provider(s):



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