Assessment – Internet Addiction Test

I consent to engage in remote psychological testing services through CatholicPsych Institute. I understand that remote testing services may include consultation, interview, assessment, testing, diagnosis, transfer of medical data, telephone conversations, feedback, and/or education using interactive audio, video, or data communications. I understand that the standard administration of these procedures involves in-person, face-to-face methods and that the impact of applying non-standard administration methods has been evaluated only in part by scientific research. While much of the research so far is supportive and will every effort will be made to simulate standard assessment practices, the diagnostic conclusions and recommendations for treatment provided in this report are being advanced with these reservations.


I understand that I have the following rights with respect to remote testing services:

1. I have the right to withhold or withdraw consent at any time without affecting my right to future testing, care or treatment.

2. I understand that the remote format might pose additional risks to privacy and confidentiality. Confidentiality still applies for telepsychology services, and nobody will record the session or materials without written permission from the other person. I understand that the information disclosed by me during the course of remote testing services is generally confidential. However, there are limits and exceptions to confidentiality with remote services, just as there are with in-person testing services. These include, but are not limited to, reporting child, elder, and dependent adult abuse and expressed threats of harm.

3. I understand that there are risks and consequences from remote testing services, including, but not limited to, the possibility, despite reasonable efforts on the part of CPI that: the transmission of my information could be disrupted or distorted by technical failures, the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.

4. I understand that I am responsible for providing the necessary telephone or internet-connected devices and internet access for my remote testing services and arranging a location with sufficient privacy that is free from distractions or intrusions. It is important to use a secure internet connection rather than public/free Wi-Fi.

5. I agree that I will not publish, photograph, scan, or disseminate the test materials. I will not capture images, take screen shots or other photographs of test materials, or record sessions to work with the psychologist in protecting test security.

5. I certify that I am the only one answering questions and that I am not sharing the assessment materials, nor completing the materials with another individual.

6. I understand the same fee rates will apply for remote testing services as apply for in-person services. Although CPI does not submit invoices for insurance payment, some testing clients may choose to submit these invoices for reimbursement after paying for CPI services. However, insurance or other managed care providers may not cover sessions that are conducted via telecommunication. If I wish reimbursement, it is my responsibility to contact my insurance company prior to engaging in remote testing services in order to determine whether these services will be covered.

7. I understand that remote services through CPI will only be conducted through telephone and/or online video services. Professional services will not be provided through email or text. Email and text communications with my clinician may only be used for setting or adjusting appointments.

8. I understand that I have additional rights and responsibilities, which are outlined in the document Informed Consent, which I have also been provided. By checking the box, I acknowledge that I have both read and understood the information in this document and agree to the terms.