Telehealth consent
Last updated October 2, 2026
Draft for attorney review. Not yet in effect.
Effective date: [EFFECTIVE DATE]
Please read this before you begin your assessment. You will be asked to confirm that you have read and agree to it. If you have questions, email [CONTACT EMAIL] before you continue.
What telehealth means here
Telehealth means receiving health care services through secure electronic communication instead of in person. For our service, it includes:
- An online questionnaire you complete on your own device
- Review of your responses by a state-licensed clinical psychologist
- A live, two-way video consultation with that psychologist
- Delivery of your written report and superbill electronically
The psychologist who evaluates you is licensed in the state where you are located at the time of your appointment. [COMPANY LEGAL NAME] operates the platform through which these services are delivered.
What this service is and is not
This is a diagnostic evaluation for ADHD in adults aged 18 and older. The outcome is a clinical opinion based on DSM-5-TR criteria, a written report, and a superbill.
It is not treatment. We do not prescribe medication, provide therapy, or offer ongoing care. It is not a general mental health evaluation, although we screen for common co-occurring conditions and will tell you if we notice something that deserves follow-up.
You may complete the evaluation and not meet criteria for ADHD. A thorough evaluation can also be limited by the information available, and no diagnostic method is perfect.
Benefits of telehealth
- You can complete the evaluation from home, at your own pace, without travel
- Appointments are often available sooner than in-person evaluations
- Some people find it easier to be candid about difficult topics from a familiar place
Risks and limitations
- A clinician cannot observe you as fully by video as in person, and cannot perform a physical examination
- Technology can fail or be interrupted, delaying or cutting short your appointment
- Electronic communication carries some privacy risk, even with strong safeguards
- The clinician relies on what you report, so incomplete or inaccurate information can lead to an incomplete or inaccurate conclusion
- Telehealth may not be appropriate for everyone. If the clinician believes an in-person evaluation would serve you better, they will say so
Privacy and confidentiality
Your information is protected by HIPAA and by state law. We use encrypted platforms for the questionnaire, video appointments, and record storage. Our Notice of privacy practices explains how your health information may be used and disclosed and the rights you have.
Confidentiality has limits that apply to all mental health professionals. A clinician may be required to disclose information when there is a serious risk of harm to you or others, when abuse or neglect of a child, elder, or dependent adult is suspected, or when a court orders it. Your clinician will explain these limits if they become relevant.
To protect your own privacy, join your appointment from a private space where you will not be overheard, and do not share your resume link or results link with others.
Recording
We do not record video consultations. Please do not record the appointment without the clinician’s agreement.
Technology requirements and failures
You will need a device with a camera and microphone, a stable internet connection, and a private location. If the video connection fails during your appointment, your clinician will try to reconnect by video, then by phone at the number you provided. If the appointment cannot be completed, we will reschedule the remaining time at no additional cost.
Emergencies
Telehealth is not suitable for emergencies, and our service is not monitored continuously. If you are in crisis, thinking about suicide or self-harm, or worried about your immediate safety or someone else’s:
- Call or text 988 to reach the Suicide and Crisis Lifeline, available 24 hours a day
- Call 911 or go to your nearest emergency room
If a safety concern arises during your appointment, your clinician may need to contact emergency services in your location. For that reason, we ask you to confirm your physical address and an emergency contact before the appointment.
Location verification
Licensing laws require that you be physically located in a state where your clinician is licensed at the time of the video appointment. We will ask you to confirm your location before and at the start of the appointment. If you are not in an eligible location, the clinician cannot proceed and the appointment will need to be rescheduled under our Refund policy.
Your rights
You have the right to:
- Ask questions about the evaluation at any time
- Decline to answer any question, understanding that this may limit the conclusions the clinician can draw
- Withdraw your consent and stop the evaluation at any time, subject to our Refund policy
- Receive a copy of your report and records
- Seek an in-person evaluation elsewhere instead
Withdrawing consent will not affect your ability to use our service in the future.
Your agreement
By checking the consent box and continuing, you confirm that:
- You are at least 18 years old and are completing this evaluation for yourself
- You have read and understood this consent, or have had it explained to you
- You understand the benefits, risks, and limits of telehealth described above
- You understand that this is a diagnostic service and does not include prescribing or treatment
- You agree to receive psychological evaluation services by telehealth
Contact
[COMPANY LEGAL NAME] [REGISTERED ADDRESS] Email: [CONTACT EMAIL]