Tele-psychological Services 

Please review and complete the following form to indicate your consent to engage in tele-psychological services before your scheduled appointment.

Tele-psychological Services include the provision of psychological services using telecommunication technologies that allow for the preparation, transmission, communication of processing of personal health information by electronic means. These technologies may include telephone, mobile devices, videoconferencing, email, text, chat and internet-based services (e.g., social media).

To help you engage in these services, our clinic staff and clinicians have considered the following factors in order to conduct tele-psychological services:

  1. Each clinician has screened children/families to determine whether video conferencing services are appropriate for you.
  2. We have considered your child’s clinical, developmental, and cognitive status; that is, can your child effectively participate?
  3. Do you have technology resources for a videoconference – for example, a smartphone or computer?
  4. Each clinician will consider a child’s and family’s comfort in using technology – can they log in and effectively use the technology?
  5. Do you have physical space for a private tele-psychology session?
  6. We are considering patient safety related to mental health status, health concerns (e.g. viral risk; mobility; immune function), community risk, and psychologist/staff health when deciding to do tele-psychology sessions instead of in-person.

As clinicians, we will do the following:

  • Make sure our room is well lit to ensure picture quality.
  • We will ensure audio quality is good.
  • To improve eye contact, we will position our camera so that it’s easy to look at the camera and you on screen.
  • All individuals present for the virtual visit must be within view of the camera so the psychologist is aware of who is participating.
  • We will remove personal items or distractions in the background to ensure sessions are focused on your care.
  • We will answer any questions you have regarding the potential risks/benefits of tele-psychology sessions with your child and you.
  • We will turn off all apps and notifications on our computer or smartphone. We will ask you to do the same.
  • We will obtain a signed informed consent from each patient (child/adolescent) or from patient’s legal representative.
  • Given that our province is in a declared state of emergency, all consent must be signed electronically.
  • In case of a crisis situation, we will offer telephone consultation and provide direction re: next best steps for plan of care.
  • Each clinician will confirm that sessions are not recorded.

Our administrative staff will do the following to ensure this process runs smoothly:

  • We are using a system called ZOOM which our administration staff can help you set up, or we can offer telephone therapy sessions.
  • Our staff will advise you that we are using a technology platform (ZOOM) consistent with HIPAA-compliant practices to allow for increase security and protection of the sessions.
  • They will discuss how each session will be billed. Each session will be billed in accordance to our current policy and procedures; that is, following an appointment, you will receive a bill via email and you will be asked to pay via e-transfer or credit card.
  • Our administration has set up home offices. If you need a physical copy of your receipt, that can be provided to you by Dr. Pure who has access to the clinic and will be able to print and mail as needed.
  • Our administration will confirm your location and best contact number where you can be reached for tele-psychological services.
  • We will ask for a phone number where you can be reached should there be an interruption in session due to technical issues.
  • Our administration will set up all tele-psychology sessions, and/or phone calls, and will confirm these appointments with you.
  • Our administration will confirm with you that the session is not recorded.
  • Please ask your insurer if they will cover the costs for psychological services provided by tele-psychology.
  • By typing your name below, you are indicating that you have read and understand this consent form.
    First and last name of parent/guardian.