Online Therapy Practice Policies
ONLINE THERAPY (TELETHERAPY) SERVICES AGREEMENT & INFORMED CONSENT
DEFINITION OF SERVICES
TeleTherapy services are a form of psychological therapy service which is provided via secure internet technology.
Specifically, TeleTherapy involves a therapist and a client interfacing via their computers over the internet at a
prearranged time. It has the same purpose or intention as face-to-face psychotherapy treatment sessions, though it
is not a universal substitute for this type of service. The TeleTherapy services provided by RoBards Counseling, Inc. occurs in the state of KentuckyUSA) and are thus governed by the laws of this state.
CLIENT REQUIREMENTS
Clients who are at risk of harm to themselves or others are not suitable for TeleTherapy services. If you become
suicidal or homicidal during treatment, please inform Amber Pearson and we will discuss options that will be more
suited for you.
TECHNOLOGY REQUIREMENTS
You will need the following in order to engage in TeleTherapy sessions:
• A computer with:
o A webcam and audio ability
o Either a Google Chrome or Mozilla Firefox web browser
Note: Internet Explorer and Safari are not supported browsers
o Internet access during scheduled sessions
• A phone (in case of technical difficulties)
In addition, in order to avoid being overheard by anyone in your vicinity during TeleTherapy, it is important that you
place yourself in a private room. It is your responsibility to create a comfortable environment and safe environment
on your end, while it is the responsibility of Michael RoBards, LCSW to create the same on his end.
TELETHERAPY SERVICE PROVIDER
The TeleTherapy service providers used by RoBards Counseling meet privacy and confidentiality standards according to HIPAA requirements.
RISKS AND RIGHTS OF TELETHERAPY SERVICES
1. You have the right to withdraw from TeleTherapy service at any time. If you choose not to utilize
TeleTherapy services it will not affect your right to further treatment, and you can continue face-to-face
therapy with Amber Pearson.
2. TeleTherapy services may not be an appropriate treatment modality for every client and, at times, may
even be counter-productive. Amber Pearson reserves the right as your therapist to determine if
TeleTherapy sessions are not in your best interest. If this is determined, Amber Pearson will continue face-
to-face services with you or provide referral information if necessary.
3. The same laws and policies which are stated in the MANDATORY DISCLOSURE & CONSENT FOR TREATMENT
form in regards to regular psychotherapy, confidentiality, exceptions of confidentiality, etc. - also apply to
TeleTherapy services.
4. It is possible that a TeleTherapy session may be disrupted or distorted by unforeseen technical issues. If you
are disconnected during a session due to a technological issue, Michael RoBards will attempt to reconnect with you.
5. The CANCELLATION & NO SHOW POLICY remains the same for TeleTherapy services. If you are unable to
connect to a TeleTherapy appointment at the allotted time, please let Michael RoBards know – otherwise your session will be considered a “No Show.” In circumstances
where a connection cannot be made due to technical difficulties in the time allotted for a session (and you
called Michael RoBards for assistance), you will not be charged a fee.
6. I accept that TeleTherapy is NOT designed for and will not be used as an emergency service.
7. Although all efforts are made to ensure high encryption and security in technology used, there is always a
risk that transmission may be breached or accessed by unauthorized users.
8. You are responsible for making payments for TeleTherapy services that you participate in.
By signing below, you agree that you have read, understand, and agreed to the above TELETHERAPY SERVICES
AGREEMENT & INFORMED CONSENT. In addition, you will assume all of the foregoing risks and accept personal
responsibility for confidentiality issues regarding TeleTherapy services and recuse Michael RoBards, RoBards Counseling, and its staff from any liability if confidentiality is breached when these
communications occur.
DEFINITION OF SERVICES
TeleTherapy services are a form of psychological therapy service which is provided via secure internet technology.
Specifically, TeleTherapy involves a therapist and a client interfacing via their computers over the internet at a
prearranged time. It has the same purpose or intention as face-to-face psychotherapy treatment sessions, though it
is not a universal substitute for this type of service. The TeleTherapy services provided by RoBards Counseling, Inc. occurs in the state of KentuckyUSA) and are thus governed by the laws of this state.
CLIENT REQUIREMENTS
Clients who are at risk of harm to themselves or others are not suitable for TeleTherapy services. If you become
suicidal or homicidal during treatment, please inform Amber Pearson and we will discuss options that will be more
suited for you.
TECHNOLOGY REQUIREMENTS
You will need the following in order to engage in TeleTherapy sessions:
• A computer with:
o A webcam and audio ability
o Either a Google Chrome or Mozilla Firefox web browser
Note: Internet Explorer and Safari are not supported browsers
o Internet access during scheduled sessions
• A phone (in case of technical difficulties)
In addition, in order to avoid being overheard by anyone in your vicinity during TeleTherapy, it is important that you
place yourself in a private room. It is your responsibility to create a comfortable environment and safe environment
on your end, while it is the responsibility of Michael RoBards, LCSW to create the same on his end.
TELETHERAPY SERVICE PROVIDER
The TeleTherapy service providers used by RoBards Counseling meet privacy and confidentiality standards according to HIPAA requirements.
RISKS AND RIGHTS OF TELETHERAPY SERVICES
1. You have the right to withdraw from TeleTherapy service at any time. If you choose not to utilize
TeleTherapy services it will not affect your right to further treatment, and you can continue face-to-face
therapy with Amber Pearson.
2. TeleTherapy services may not be an appropriate treatment modality for every client and, at times, may
even be counter-productive. Amber Pearson reserves the right as your therapist to determine if
TeleTherapy sessions are not in your best interest. If this is determined, Amber Pearson will continue face-
to-face services with you or provide referral information if necessary.
3. The same laws and policies which are stated in the MANDATORY DISCLOSURE & CONSENT FOR TREATMENT
form in regards to regular psychotherapy, confidentiality, exceptions of confidentiality, etc. - also apply to
TeleTherapy services.
4. It is possible that a TeleTherapy session may be disrupted or distorted by unforeseen technical issues. If you
are disconnected during a session due to a technological issue, Michael RoBards will attempt to reconnect with you.
5. The CANCELLATION & NO SHOW POLICY remains the same for TeleTherapy services. If you are unable to
connect to a TeleTherapy appointment at the allotted time, please let Michael RoBards know – otherwise your session will be considered a “No Show.” In circumstances
where a connection cannot be made due to technical difficulties in the time allotted for a session (and you
called Michael RoBards for assistance), you will not be charged a fee.
6. I accept that TeleTherapy is NOT designed for and will not be used as an emergency service.
7. Although all efforts are made to ensure high encryption and security in technology used, there is always a
risk that transmission may be breached or accessed by unauthorized users.
8. You are responsible for making payments for TeleTherapy services that you participate in.
By signing below, you agree that you have read, understand, and agreed to the above TELETHERAPY SERVICES
AGREEMENT & INFORMED CONSENT. In addition, you will assume all of the foregoing risks and accept personal
responsibility for confidentiality issues regarding TeleTherapy services and recuse Michael RoBards, RoBards Counseling, and its staff from any liability if confidentiality is breached when these
communications occur.
