Engaging in our therapy session through a video call (telehealth) creates unique risks, while also having benefits. It is important to Dr. Dillmann, that you fully understand the risks and efforts to minimize them.

The main risks have to do with limits to your confidentiality, as well as limits to the privacy and security of your personal information, which is shared during the use of the video call. With regards to your confidentiality, all of the confidentiality laws apply and Dr. Dillmann is not recording the session or taking photos of you. Dr. Dillmann conducts the video calls from either her home office or office. It is important that you also find a private, quiet space, free from distractions, in which to have this video call, so that others do not overhear or see you.

The platform used for the video call, www.doxy.me, complies with the HIPAA and HITECH laws. It also meets the privacy standards of the EU, which is on the vanguard of electronic/internet/online privacy - all to say that doxy.me follows the strongest privacy and security standards. In addition to following these laws, doxy.me does not gather any data on you or from our video call nor do they record or archive our call. Doxy.me does gather data on the time, date and length of the call i.e. our session, which they do encrypt. By signing this form and participating in the video call, you are agreeing to use doxy.me.

At the beginning of the video call, doxy.me requires you to enter a name into a form fill box, which lets Dr. Dillmann know that you are ready for the call, please feel free to enter in an initial or fake name, for another layer of security. Since you and Dr. Dillmann have scheduled the session, she knows that you are waiting for the call. Due to this being a video call, you will need to use a smart phone, computer or tablet to engage in the call. The microphone and camera on your device will be utilized in the call.

Dr. Dillmann is accessing Doxy.me through a secure (password protected) and private Wi-Fi connection. Dr. Dillmann maintains up to date antivirus protection on her computer. You are encouraged to do the same, as an unsecured connection could make you/our call vulnerable to breaches in security and privacy.

If our video call is dropped or the quality of sound or sight becomes too compromised, then Dr. Dillmann will end the call and contact you by phone, thus allowing your session to continue. You will be billed for your whole session even though this drop in the video call occurred.

Lastly, due to this being a video call, our ability to assess each other’s non-verbal cues, body language and facial expressions may be limited – so feel free to clarify any confusions on that front. It ought to be noted that video calls will not be the most effective form of therapy for certain individuals or presenting problems.

My signature below shows I understand & agree with these statements & have had my questions answered.

_______________________________________      _______

Signature of client                                                     Date

The client, based on behaviors & responses, is deemed fully competent to give informed & willing consent.

                                                                                    _______  

Susanne M. Dillmann, Psy.D, PSY21969                  Date    Copy accepted by client    Client declined copy