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Consent for Telepsych Services

Consent for Telepsych Services

What are Telepsychiatric Services?

Telepsychiatric services are used when the psychiatrist cannot be physically present with you to evaluate your mental health needs and, if appropriate, provide medications. The psychiatrist may be present at another location, to serve you through newly available technology. Telepsychiatric services use video and audio technology to send both voice and visual images between you and the designated psychiatrist. The combination of visual and audio make it possible for your psychiatrist to make a better evaluation of your needs.

How do Telepsychiatric services work?

You will be in a private room by yourself, or with a family member. The room will have a computer screen with a video camera. The Psychiatrist will also be in a private room at another location with similar equipment. When the session is ready to begin program staff will start the computer and camera so you and your Psychiatrist can see each other and talk together. When the session is over you can exit the room and inform the program staff that your session is completed.

What happens if I choose not to consent to Telepsychiatric Services?

If you choose not to consent to Telepsychiatric services, you will be provided with an onsite psychiatrist to provide you face-to-face psychiatric care.

Telemedicine privileges shall include consulting, prescribing, rendering a diagnosis or otherwise providing clinical treatment to patients through the use of visual & audio technology.


Telepsychiatry is the delivery of psychiatric services using interactive audio and visual electronic systems where the psychiatrist and the patient are not in the same physical location.

The interactive electronic systems used in telepsychiatry incorporate network and software security protocols to protect the confidentiality of patient information and audio and visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.

My Rights

  • I understand that the laws that protect the privacy and confidentiality of medical information also apply to telepsychiatry. 
  • I understand that the technology used is encrypted to prevent the unauthorized access to my private medical information.
  • I have the right to withhold or withdraw my consent to the use of telepsychiatry during the course of my care at any time. I understand that my withdrawal of consent will not affect any future care or treatment.
  • I understand that the Psychiatrist has the right to withhold or withdraw his consent for the use of telepsychiatry during the course of my care at any time.
  • I understand that the all rules and regulations which apply to the practice of medicine in the state of California also apply to telepsychiatry.
  • I understand I may not have any face to face contact with my psychiatrist, except for my telepsychiatry visits.

My Responsibilities

Telepsychiatry sessions will not be recorded without written consent. I understand that the psychiatrist will not record any of our telepsychiatry sessions without my written consent.

The psychiatrist will I will inform you if any other person can hear or see any part of our session before the session begins.

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