Consent for Telehealth Form

Please fill out the form below or download the Consent for Telehealth Form with the button above and fill it out at your convenience. Please email us if you have any questions. You can send completed paper forms to:

403 W. Cool Dr.
STE 107
Tucson, AZ 85704

or fax to:
520.329.8311

  • This Informed Consent for Telehealth contains important information focusing on rendering Neuropsychological screenings using the phone or the Internet. Please read this carefully, and let our office know if you have any questions.

    Benefits and Risks of Telehealth

    Telehealth refers to rendering services remotely using telecommunications technologies, such as video conferencing or telephone. Telehealth, however, requires technical competence on both our parts to be helpful. Although there are benefits of telehealth, there are some differences between in-person visits and telehealth, as well as some risks. For example:

    • Risks to confidentiality. Because telehealth sessions take place outside of the psychologist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. On my end I will take reasonable steps to ensure your privacy. But it is important for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in Telehealth only while in a room or area where other people are not present and cannot overhear the conversation.
    • Issues related to technology. There are many ways that technology issues might impact telehealth sessions. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies.
    • Emergency Contact. The Emergency Contact Consent Form must be filled out prior to the fist Telehealth session.

    Electronic Communications

    The videoconferencing software is web-browser based, and uses relatively common software. You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software to take part in telepsychology.

    For communication between sessions, we only use email communication with your permission and only for administrative purposes unless we have made another agreement. This means that email exchanges with our office should be limited to administrative matters. This includes things like setting and changing appointments.

  • Date Format: MM slash DD slash YYYY
  • **If signing on behalf of the patient, you must provide our office a copy of the Power of Attorney or proof of legal guardianship.

By clicking the submit button, you authorize the transmission of your personal health information to be sent over email. We take every effort to ensure that your information stays safe. All information is double encrypted and password protected.