(708) 535-7320
6006 W. 159th St, Bldg. C
Oak Forest, IL 60452

Informed Consent For Telepsychology Sessions

This Informed Consent for Telepsychology contains important information focusing on doing psychotherapy using the phone or the Internet. Please note that The Genesis Therapy Center is offering the option for Telepsychology sessions due to the unprecedented nature of the current Covid-19 virus outbreak and Center for Disease Control guidelines that people participate in social distancing of 6 feet or more. Genesis recognizes the need for some clients to continue receiving outpatient therapy services, when an in-office visit is not feasible, and is offering the option to virtually meet with your therapist. 

Benefits and Risks of Telepsychology

Telepsychology refers to providing psychotherapy services remotely using telecommunications technologies, such as video conferencing or telephone.  One of the benefits of telepsychology is that the client and clinician can engage in services without being in the same physical location. Telepsychology, however, requires technical competence on both our parts to be helpful.  Although there are benefits of telepsychology, there are some differences between in-person psychotherapy and telepsychology, as well as some risks.  For example:

  • Risks to confidentiality.  Because telepsychology sessions take place outside of the therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. Genesis’ therapists will take reasonable steps to ensure your privacy. But it is important for you to make sure you find a private place for the session where you will not be interrupted.  It is also important for you to protect the privacy of the session on your cell phone or other device.   You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation.
  • Issues related to technology.  There are many ways that technology issues might impact telepsychology.  For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies.  
  • Crisis management and intervention.  Genesis’ therapist recognize that telepsychology is not an appropriate intervention for crisis management.  If a client is in crisis, Genesis’ therapist will advise you to go to your nearest emergency room or call 911. 
  • Efficacy. Most research shows that telepsychology is about as effective as in-person psychotherapy. However, some therapists believe that something is lost by not being in the same room. For example, there is debate about a therapist’s ability to fully understand non-verbal information when working remotely.

Electronic Communications

We will decide together which kind of telepsychology service to use.  You may have to have certain computer or cell phone systems to use telepsychology services. You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software to take part in telepsychology.


The Genesis Therapy Center has a legal and ethical responsibility to make best efforts to protect all communications that are a part of telepsychology.  However, the nature of electronic communications technologies is such that it cannot guarantee that communications will be kept confidential or that other people may not gain access to these communications. As with any electronic communication, there is an inherent risk that the electronic communications may be compromised, unsecured, or accessed by others.  You should also take reasonable steps to ensure the security of communications (for example, only using secure networks for telepsychology sessions and having passwords to protect the device you use for telepsychology).  

The extent of confidentiality and the exceptions to confidentiality remain the same as outlined in the Client Information and Informed Consent (signed at your intake session) still apply in telepsychology. As well, so do the emergency procedures should a crisis arise, go to your nearest emergency room or call 911. Please let me know if you have any questions about exceptions to confidentiality or the emergency procedure.

 Assessing and evaluating threats and other emergencies can be more difficult when conducting telepsychology than in traditional in-person therapy.  To address some of these difficulties, we will create an emergency plan before engaging in telepsychology services.  I will ask you to identify an emergency contact person who is near your location and who I will contact in the event of a crisis or emergency to assist in addressing the situation.  By signing this form you are allowing me to contact your emergency contact person as needed during such a crisis or emergency. 

  • If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call me back; instead, call 911, or go to your nearest emergency room. Call me back after you have called or obtained emergency services.

    If the session is interrupted and you are not having an emergency, disconnect from the session and I will wait two (2) minutes and then re-contact you via the telepsychology platform on which we agreed to conduct therapy. If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time.

    Fees If No Insurance Coverage for Teletherapy With Genesis

    You have chosen to contract for telepsychology services as your insurance coverage either does not cover such treatment or does not cover such treatment with your provider of choice. Therefore, you agree to have the credit card on file charged the agreed upon rate of $ . for 45 minutes of telepsychology or $ . for 30 minutes of telepsychology ______(Initial). This fee is your financial responsibility and not reimbursable by insurance.

  • Fee If Insurance Coverage Includes Teletherapy With Genesis as a Covered Provider

    You have chosen to contract for telepsychology services and your insurance plan has stated it will cover treatment by a Genesis therapist. As the client, you are responsible to verify coverage and the parameters your policy requires for telepsychology. Genesis will discuss options for services within these guidelines and submit billing to your insurance provider in a manner in line with the services provided. Clients will be responsible for any charges deemed their responsibility by the insurance provider.


    The telepsychology sessions shall not be recorded in any way unless agreed to in writing by mutual consent. Genesis will maintain a record of the telepsychology session in the same way records are currently maintained for in-person sessions..

    Informed Consent

    This agreement is intended as a supplement to the Client Information and Informed Consent signed and agreed to at the onset of our clinical work together and does not amend any of the terms of that agreement.

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