New Telehealth/Teleneuropsychology Services

sharon@drsharonegilbert.com
516-686-6497
917-842-6864

Telehealth/Teleneuropsychology Services

Informed Consent Addendum: Telehealth/Teleneuropsychology Services
In addition to the information contained in the Informed Consent, the following information applies to the use of electronic methods of clinical service delivery. Please read carefully before signing and do not hesitate to present Dr. Gilbert with any questions or concerns that you have.

Introduction:
Telepsychology services are a new and innovative way to deliver mental health treatment, including pain psychology, using electronic means of communication. Because telepsychology is so new, the technology, requirements for use, and insurance reimbursement associated with it are continually changing. We work hard to keep up with the latest information and do our best to update you as changes occur that could affect you. However, we may not be able to predict these changes before they occur.

As the client or parent/guardian of a client receiving testing or psychological services through telehealth technologies, I understand:

… Telehealth/teleneuropsychology is the delivery of testing and psychological services using interactive technologies (use of audio, video or other electronic communications) between a practitioner and a client/patient who are not in the same physical location.

… The interactive technologies used in telehealth/teleneuropsychology incorporate network and software security protocols to protect the confidentiality of client information transmitted via any electronic channel. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.

… This service is provided by technology and may include but is not limited to video, phone, apps, and email. There are benefits and limitations to this service.
- There are risks in transmitting information over technology that include, but are not limited to, breaches of confidentiality and disruption of service due to technical difficulties. If there is any concern about a privacy breach, the session will be ended immediately. If there is sudden loss of service or technological glitch in the session due to failure of a platform or internet connection on either end, Dr. Gilbert will attempt to contact you again through the platform. If unsuccessful, then she will attempt to contact you by phone to problem-solve the issue. If a secure connection cannot be re-established, the testing session may need to be rescheduled and will be discussed with you.
- The use of technology allows for greater convenience and immediacy in service delivery. While the research on the feasibility and reliability of telehealth-based neuropsychological assessment is growing and favorable, results from most test measures are typically interpreted based on using conventional in-person procedures. Dr. Gilbert will be utilizing best practice guidelines for remote testing including strategic selection of standardized tests that are amenable to the telehealth format and interpreting results accordingly. If you or Dr. Gilbert determine that telehealth/teleneuropsychology services are not the appropriate option for you or your child, testing will be discontinued, and in-person assessment will be recommended to resume when contact precautions are lifted.
Compliance with Legal Policies Regarding Replication or Distribution of Testing Items/Materials and Test Integrity:
Any reproduction or dissemination of any of the test materials that are presented during the evaluation is strictly prohibited and constitutes an infringement on copyright and other proprietary rights in the tests. Thus, video or audio recording, taking photos, image capturing system, replication, or disclosure of any of the testing information in any manner is illegal.

Providing, receiving, or seeking assistance from outside sources or tools (e.g., input from others, searching on the internet) is not allowed and any indication of compromised test integrity will result in discontinuation of the testing session and results based on that performance will be deemed unusable.

By signing below, you confirm that you have read and understand the information and policies presented in this document, that any questions/concerns presented have been addressed adequately, and that you consent to initiate telehealth/teleneuropsychology testing.
Name of Client
Date of Birth
DD slash MM slash YYYY
Digital Signature of Parent/Legal Guardian of client
Date
MM slash DD slash YYYY
Digital Signature of client (if over 9 years of age)
Date
MM slash DD slash YYYY
Please do not hesitate to contact me with any questions.

Sharone N. Gilbert, Psy.D.
Licensed Clinical Psychologist
NYS License #: 017004-1

1157 Willis Avenue, Suite 101
Albertson, NY 11507

www.drsharonegilbert.com
sharone@drsharonegilbert.com
917-842-6864
516-686-6497

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