This form is used to provide you with information about our institution and to gain your approval for services to be provided. Please read this form thoroughly and bring any questions or concerns to the attention of the intake interviewer.
You will receive mental health services in the form of psychological assessment(s) and therapy. The goal of the evaluation is to evaluate the nature of, and the extent to which, you may be experiencing psychological or emotional difficulties as a result of your injury, as well as to provide treatment recommendations. The scope of the evaluation is mostly limited to symptoms found frequently in MVA situations (e.g., anxiety, depression, trauma, phobia).
Video conferencing provides benefits and drawbacks that are distinct from face-to-face meetings (e.g., patient confidentiality).
Telepsychology services are still private, and no one will record a session without the consent of the other party(s).
We agree to use the video-conferencing platform that the psychotherapist/psychologist has selected for our virtual sessions, and we will be shown how to use it by the psychotherapist/psychologist.
You must utilize a webcam or a smartphone during the session.
You should be in a quiet, secluded location free of distractions during the session (such as telephones or other electronics).
It is vital to have a secure internet connection rather than using public or free Wi-Fi.
Acknowledgment & Consent
I have read and fully comprehended the preceding information and agree to seek clarification if I have any questions about the treatment process, its goals, procedures, potential dangers, or expected outcomes. I accept that I am allowed to terminate services at any moment for any reason. I am aware that the security of my information has some limitations.
By signing below, I accept that this institution may collect, use, and disclose personal information about me in the ways described above.