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When you agree to receive TeleHealth psychotherapy services through SimplePractice:

  1. You understand that my health care provider wishes me to engage in a telehealth consultation.

  2. You understand that video conferencing is not the same as face to face in that you will not be in the same room with the provider. Telehealth is a proven effective technological method for provision of mental health services.

  3. You understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

  4. You understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. you understand that my health care provider or you can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

  5. If there is any failure in connectivity, interrupting the normal flow of the session, a phone call will be used to complete the session.

  6. You should treat these sessions just like regular mental health sessions with my provider. you should be on time and adequate clothing is required.

  7. My environment is only able to be controlled by me. you should make sure to ensure you am in a private setting and that there will be no to minimal interruptions. Pueblo Pioneer Psychology encourage you to use an independent room with door.

  8. You understand you will have the opportunity to have a direct conversation with my provider, during which you will have the opportunity to ask questions regarding this procedure.


Telehealth by SimplePractice is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, you acknowledge:

  1. Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, you will use a phone to call 911 or go to my nearest emergency care unit.

  2. Though my provider and you may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical services or advice including, but not limited to, emergency or urgent medical services.

  3. The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any medical advice or care.

  4. you do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. you will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.

  5. To maintain confidentiality, you will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

By agreeing to TeleHealth services you certify:

  • That you have read or had this form read and/or had this form explained to me.

  • That you fully understand its contents including the risks and benefits of the procedure(s).

  • That you have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

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