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Informed Consent for Telepsychology
Purpose: This form provides information about psychological services delivered via telecommunication technology (telepsychology) by Dr. Odell Vining, a licensed psychologist in Alabama and Georgia, and obtains your consent to participate.
Telepsychology Services Include:
Benefits:
Risks:
Client Responsibilities:
Emergency Procedures:
Confidentiality:
Consent: I understand the benefits, risks, responsibilities, and procedures described above. I consent to receive telepsychology services from Dr. Odell Vining, who is licensed in Alabama and Georgia, and potentially under PSYPACT authority for other states, if applicable. I have received and reviewed the HIPAA Notice of Privacy Practices.
HIPAA Notice of Privacy Practices (Telehealth Version)
The Psychology Clinic
Phone: 706-225-0322
Email: office@thepsychologyclinic.com
Telehealth Technology Agreement
I understand that: