Telepresence Agreement Form


This Informed Consent for Telemental Health Services contains important information focusing on doing psychotherapy using the phone or the Internet.  Please read this carefully, and let me know if you have any questions.  When you sign this document, it will represent an agreement between us.

Benefits and Risks of Telemental Health:  Telemental Health refers to providing psychotherapy services remotely using telecommunications technologies such as video conferencing or telephone.  One of the benefits of Telemental Health is that the client and clinician can engage in services without being in the same physical location.  This can be helpful in ensuring continuity of care during the Covid-19 pandemic.  It is also convenient and takes less time.  Although there are benefits of Telemental Health, there are some differences between in-person psychotherapy and Telemental Health, as well as some risks.  For example,

Risk to confidentiality:  Because Telemental Health sessions take place outside of the therapist’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 endure 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 therapy 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 Telemental Health. For example, technology may stop working during a session, other people may be able to get access to our private conversation or stored data could be accessed by unauthorized people or companies.

Efficacy: Most research shows that Telemental Health is about as effective as in person psychotherapy.  However, some therapists debate about whether or not a therapist can fully understand non-verbal information while working remotely.  I will do my best to be fully attentive to you both verbally, emotionally, and physically.

Electronic communication:  We will decide together which; kind of telepsychology to use.  You may have to have certain computer or cell phone systems to use telepsychology services.  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:I only use email communication and text messaging with your permission and only for administrative purposes unless we have made another agreement.  This means that email exchanges and text messages will be limited to administrative matters.  You should be aware that I cannot guarantee the confidentiality of any information communicated by email or text.  Therefore, I will not discuss any clinical information by email or texts and prefer that you do not either.  Also, I do not regularly check my emails, so this method should not be used if there is an emergency.

If an urgent issue arises, please feel free to text me to call you as soon as possible.  If I am on vacation, I will provide you with the name of a therapist on call.  You can also contact your physician or go to the nearest hospital emergency room.

Confidentiality: I have a legal and ethical responsibility to protect communications that are part of Telemental Health.  However the nature of electronic communications technologies is such that I cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications.  You should always take reasonable steps to ensure the security of our communications (for example, by using secure networks and passwords for our sessions).  The extent of confidentiality and the exceptions to confidentiality are outlined in the Client Information form that you have also signed.

If the session is interrupted and you are not having an emergency, disconnect from the session and I will attempt to reach out to you.  If you do not hear back from me in 5 minutes, please call me on my cell at 302-598-2883.

If you are having an emergency, and we can’t reconnect via telehealth or by phone, please call 911, or go to your nearest hospital emergency room..

Records: I will not be recording our session unless we both agree to that in writing ahead of time.  I will maintain a record of our session in the same way I maintain records of in-person sessions in accordance with my policies. Upon signing this agreement, you are also agreeing that you too, are not recording our session.

Informed Consent:  This agreement is intended as a supplement to the general informed consent that you are signing now or have previously signed when we first began working together.  Your signature below indicates agreement with its terms and conditions.


I acknowledge that I have read and understand Meryl Brownstein’s Informed Consent for Telemental Health Services.