Telepsychology Assessment Agreement

Name(Required)
Telepsychology refers to providing psychological services remotely using telecommunication technologies, such as video conferencing, email, or telephone. The main benefit is that the recipient can receive services even if unable to meet in person. In the case of religious and seminary vocational assessments, it can be difficult to find a psychologist who is culturally and professionally competent to provide such assessments. By checking this box, I confirm that I understand the nature and purpose of telepsychology and why it would be suitable for me at this time.(Required)
Requirements for Telepsychology Evaluation: To ensure that the psychological evaluation results are as valid as possible, I agree to complete the assessment measures in the following conditions: I will ensure that I have access to adequate technological devices equipped with a reliable internet connection and zoom capabilities for the purpose of the evaluation. I will ensure that I have access to a quiet, distraction free work environment that I can guarantee will be free of interruptions for the duration of the assessment process. I will refrain from using the internet for any other purpose while completing the assigned tasks. I will not record, download, or copy any of the test materials shared with me. I will refrain from consulting another individual or websites when providing my responses.
Risks to confidentiality. Because telepsychology sessions take place outside of the therapist’s private office, there is potential for other people to overhear sessions. It is not advised to use a public access computer, to connect over nonsecure or a public network, or to use auto-fill for your username and password, as this may increase the risk that others may be able to access your private information. We will take reasonable steps to ensure privacy such as only engaging in telepsychology sessions in a private place, and when conducting video sessions, only using encrypted, HIPAA-compliant software, and a secure network. It is important that telepsychology sessions and remote work occur only in a private room or area where other people are not present, with no interruptions, and where others cannot overhear the conversation. It is also important to ensure the security of any devices and networks in use. While these steps greatly reduce the risks to confidentiality, they do not guarantee your privacy during telepsychology sessions.
Technology glitches. There are many ways that technology failures may impact telepsychology. For example, calls can get dropped, Internet connections can become weak, software can freeze or have other bugs, or stored data could be accessed by unauthorized people or companies. To reduce the risk of technological glitches interfering with the assessment process, use a reliable Internet or phone connection and secure software. For Internet-based sessions, it is best to use a private connection (rather than a public network) and a device with proper security features enabled.
For licensing purposes, I understand that I need to be located in my home state during the evaluation.
Please indicate the location where you will be participating in any telepsychology sessions and completing any assigned tasks. Verifying that it is one of the following: AL, AZ, AR, CO, CT. DE. DC, GA, ID, IL, IN, KS, KY, ME, MD, MN, MO, NE, NV, NH, NJ, NC, OH, OK, PA, TN, TX, UT, VA, WA, WV, WI
In the event that we are disconnected during our zoom call, the provider will immediately call you at the phone number you provide here.
By signing below, I acknowledge that I have received and read the “Informed Consent for Telepsychology.” My signature further signifies that I freely giving my informed consent to enter to the terms described herein. I understand that I can revoke this consent in writing at any time.