VT

How Virtual Therapy works.

As of March 20th, 2020, I have moved my entire psychotherapy practice to Virtual. Virtual Therapy sessions are done through the HIPAA compliant DOXY.ME portal. You will need to register in advance of the session. VT sessions on average are 30-45 minutes. If using insurance, you copay will need to paid at the time of the call using ZELLE/VENMO or the SquareCash app.

Virtual Therapy Informed Consent

1. I understand that I am about to engage in a Video therapy sessions with my provider, Robert Norgaard, LMFT.

2. I understand that the video conferencing technology will not be the same as an in-person session with Robert Norgaard due to the fact that I will not be in the same room as my provider. I also understand that, in order to have the best results for this session, I should be in a quiet place with limited interruptions when I start the session.

3. I understand the potential risks to this technology, include interruptions, unauthorized access and technical difficulties. I understand that my provider or I can discontinue the video therapy session if it is felt that the videoconferencing connections are not adequate for the situation.

4. I agree to inform my provider if there is another person present during the session or if I wish to tape the session.

5. I understand that this consent will last for the duration of the relationship with my provider, including any additional video therapy sessions I may have; I can withdraw my consent for a video therapy session at any time.

6. I understand that same confidentiality protections, limits to confidentiality, and rules around my records apply to a video therapy session as they would to an in-person session.

7. I agree to work with my provider to come up with a safety plan, including identifying one or two emergency contacts, in the event of a crisis situation during our sessions.

8. I understand that my provider may decide to terminate video therapy services, if they deem it inappropriate for me to continue therapy through video sessions.

9. I understand that this Informed Consent for Video/Virtual sessions in in addition to the policies I have already signed at the start of therapy with Robert Norgaard. Those forms include: Consent for Services (office policies), HIPAA, Cancellation Policy, Insurance Policy and others.

10.I also understand that the same cancellation policy applies to Virtual sessions as does to in person sessions: I require 24 hours notice to cancel a session. The cancellation fee is my session fee of $120 for cancellations with out notice, no-shows or within 24 hours. I m sorry but there are no exceptions to this policy except for a MD note.

By signing this form, I certify: ● That I have read or had this form read and/or had this form explained to me. ● That I fully understand its contents including the risks and benefits of the procedure(s). ● That I have been given opportunity to ask questions and that any questions have been answered to my satisfaction. ● That I agree to participation in a video therapy session(s) with Robert Norgaard.

________________________________________ _____________________ Client’s signature and date