7111 West 151st Street, Suite #286, Overland Park, KS 66223

TELETHERAPY INFORMED CONSENT

Teletherapy involves the delivery of psychological services using interactive audio and visual electronic systems where the psychologist and patient are not in the same physical location. The interactive electronic systems used in teletherapy incorporate network and software security protocols (encryption) to protect the confidentiality of patient information and audio and visual data.

YOUR RIGHTS, RISKS, AND RESPONSIBILITES

You need to be a resident of Kansas or Missouri or one of the states in which Dr. Benson holds a Temporary Psychology License.

You have the right to withhold or withdraw consent at any time without affecting your right to future care or treatment.

Your medical information in teletherapy is protected by the same patient privacy laws (HIPAA) that protect in-person therapy. Exceptions to confidentiality are stated in the general Informed Consent noted on my website (bensonpsyc.com) and apply to teletherapy.

You acknowledge that there are risks associated with teletherapy:

Transmission of my information could be disrupted or distorted by technical failures or unforeseen technical issues.

Transmission of my information could be interrupted by unathorized persons.

Electronic therapy of my medical information could be accessed by unathorized persons.

I may benefit from these services, but results cannot be guaranteed or assured. I may experience unpleasant, disturbing thoughts, emotions or memories during the teletherapy process.

Emergency/crisis services are not provided. I understand I must call 911 or go to the nearest hospital emergency room if I am danger of harming myself or others.

My conversations could be overheard by anyone near me if I am not in a private room or space during teletherapy. It is my responsibility to ensure a private location with sufficient lighting that is free from distractions or intrusions. It is also my responsibility to provide necessary telecommunication equipment and internet access for teletherapy to occur.

By my signature below, I hereby consent to engage in teletherapy with Richard L. Benson, Ph.D., P.A. via the telephone and/or video, which can include evaluation, diagnosis, treatment, transfer of medical data, emails, telephone conversations, and/or education using interactive audio, video, or data communication. I understand that teletherapy involves the communication of my medical/mental health information both orally and/or visuallhy.

Signature and Date Below (Parent if Patient is a Minor)

_______________________________________________________________________

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