Telepsychiatry Informed Consent Form

Patient Information

Name: _________________________ Date of Birth: _________________ Address: _______________________ Phone: ________________________

Nature of Telepsychiatry Services

I understand that telepsychiatry involves the delivery of psychiatric services using electronic communications, information technology, or other means between a psychiatrist and a patient who are not in the same physical location.

Risks and Benefits

Benefits:

• Improved access to psychiatric care
• Convenience of home-based sessions
• Reduced travel time and costs
• Continuity of care during mobility restrictions

Potential Risks:

• Technical difficulties or disruptions
• Limited physical examination capabilities
• Potential privacy/security concerns
• Emergency situation management limitations

Patient Rights and Responsibilities

1. I have the right to withhold or withdraw consent for telepsychiatry services at any time.
2. I understand that all applicable privacy laws and protections apply to telepsychiatry.
3. I will ensure a private, quiet location for my sessions.
4. I will provide accurate contact information for emergency situations.

Technology Requirements

• Reliable internet connection
• Device with camera and microphone capabilities
• Secure, HIPAA-compliant platform access
• Backup phone number for technical difficulties

Emergency Protocols

Local Emergency Contact: _________________ Phone: ________________ Nearest Emergency Department: _________________________________

Consent

I have read and understand the information provided above regarding telepsychiatry services.

Patient Signature: _________________ Date: _________________ Provider Signature: ________________ Date: _________________