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:

• Psychological evaluations
• Individual and family therapy
• Behavioral consultations
• Performance consulting

Benefits:

• Convenience and accessibility from your location
• Continuity of care without in-person visits

Risks:

• Technical failures (e.g., internet or Zoom disruptions)
• Potential data breaches, despite HIPAA-compliant encryption
• Reduced nonverbal communication cues compared to in-person sessions
• Challenges in managing emergencies remotely

Client Responsibilities:

• Ensure a private, quiet setting for sessions, free from distractions
• Use a secure, stable internet connection and a device meeting Zoom’s requirements
• Notify Dr. Vining of your physical location (city, state) at the start of each session, as services are provided under Alabama or Georgia licensure (or PSYPACT authority, if applicable)
• Do not record sessions without written consent
• Contact Dr. Vining via backup phone (706-225-0322) if Zoom fails

Emergency Procedures:

• If Dr. Vining assesses that you are at risk (e.g., suicidal ideation), appropriate emergency responders (e.g., 911, 988 Suicide & Crisis Lifeline) in your location will be contacted
• You must provide a reliable emergency contact and your current address on the Emergency Contact & Safety Plan Form
• In case of technical failure during a crisis, use the backup phone number (706-225-0322)

Confidentiality:

• Sessions are conducted via Zoom for Healthcare, a HIPAA-compliant platform with a Business Associate Agreement
• All telepsychology sessions are encrypted to protect your privacy
• Limits of confidentiality apply, including mandatory reporting of threats of harm, abuse, or other legally required disclosures
• Your records are stored securely in a HIPAA-compliant electronic health record system

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.

Emergency Contact & Safety Plan

HIPAA Notice of Privacy Practices (Telehealth Version)

• Your health information is protected by federal law (HIPAA).
• We use encrypted technology and secure storage.
• Your data will not be shared without written consent, except in legally mandated cases.
• You may request records, corrections, or file complaints.
• Contact:

The Psychology Clinic

Phone: 706-225-0322

Email: office@thepsychologyclinic.com

Telehealth Technology Agreement

I understand that:

• My sessions will take place via secure video conferencing software.
• I must use a private, stable internet connection.
• My sessions will not be recorded unless I provide written consent.
• Technical failures may occasionally interrupt sessions.
• It is my responsibility to notify Dr. Vining immediately if the connection fails.