Bonnie Connor, PhD
PSY 22446
1105 Kennedy Place, Suite 6
Davis, CA 95616
T: 530.750.1700
F: 800.390.1612

This Informed Consent for Tele-NP (Tele-neuropsychology) contains important information focusing on doing neuropsychological interviews, testing, and feedback sessions using the phone or the Internet. Please read this carefully, and let me know if you have any questions. When you sign this document, it will represent an agreement between us.

Benefits and Risks of TELE-NP
Tele-NP refers to providing neuropsychology services remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of Tele-NP is that the client and clinician can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or clinician is unable to meet in person. It may be more convenient and take less time. Tele-NP, however, requires technical competence on both our parts to be helpful. Although there are benefits of Tele-NP, there are differences between in-person neuropsychology and Tele-NP, as well as some risks. For example:

Risks to confidentiality.  Because Tele-NP sessions take place outside of the neuropsychologist’s private office, there is potential for other people to overhear our communication if you are not in a private place during the session. On my end I will take reasonable steps to ensure your privacy. It is important for you to make sure to find a private place for our sessions where you will not be interrupted. It is also important for you to protect the privacy of our sessions on your cell phone or other device. You should participate in our communication only while in a room or area where other people are not present and cannot overhear the conversation.
 
Issues related to technology.  There are many ways that technology issues might impact Tele-NP. For example, technology may stop working during a session, other people might be able to access to our private conversation, or stored data could be accessed by unauthorized people or companies.
 
Crisis management and intervention.  Usually, I will not engage in Tele-NP with clients who are currently in a crisis situation requiring high levels of support and intervention. If you are experiencing an emergency, please call 9-1-1.
 
Efficacy.  Tele-NP is an emerging field with limited research. Regarding interview and feedback sessions, most research shows that Tele-psychology is about as effective as in-person psychotherapy. However, some psychologists and neuropsychologists believe that something is lost by not being in the same room. For example, there is debate about a neuropsychologist’s ability to fully understand non-verbal information when working remotely.

Electronic Communications

We will be using Zoom for Tele-NP appointments. Before each appointment I will send you an email with a link to the session, the Meeting ID, and Password. Our practice uses modern tools and systems to help us provide better care and support. If you have any questions about these tools and how we use them, please ask.


For communication between appointments, I use email (bonnie@secure.bonnieconnor.com) and text messaging for administrative purposes which includes things like setting and changing appointments, billing matters, and other related issues. You should be aware that I cannot guarantee the confidentiality of any information communicated by email or text. Therefore, I will not discuss any clinical information by email or text and prefer that you do not either. Also, I do not regularly check my email or texts, nor do I respond immediately so these methods should not be used if there is an emergency. If I will be unavailable for an extended time, I will notify you in advance of my absence, if necessary.

Confidentiality
I have a legal and ethical responsibility to make my best efforts to protect all communications that are a part of our Tele-NP. However, the nature of electronic communications technologies is such that I cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. I will use updated encryption methods, firewalls, and back-up systems to help keep your information private. There is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should take reasonable steps to ensure the security of our communications (e.g., using secure networks for Tele-NP appointments and having passwords to protect the device you use).

The extent of confidentiality and the exceptions to confidentiality that I outlined in my Informed Consent [CONSENT FOR NEUROPSYCHOLOGICAL SERVICES] still apply in Tele-NP. Please let me know if you have any questions about exceptions to confidentiality.

Appropriateness of Tele-NP
I will let you know if I decide that Tele-NP is no longer the most appropriate form of communication between us. We will discuss options of referral to another professional in your location who can provide appropriate services.

Emergencies and Technology
If the session is interrupted, disconnect from the session. I will wait two (2) minutes and then re-contact you via the Tele-NP platform on which we agreed to conduct therapy. If you do not receive a call back within two (2) minutes, then call me on the phone number I provided you (530-750-1700).

Fees
The same fee rates will apply for Tele-NP as apply for in-person neuropsychology.
 

Payment for services rendered
I am obligated to bill your insurance company only if I am a contracted provider. I am a contracted provider for UC SHIP. With this insurance plan you agree to assignment of benefits to Bonnie Connor, PhD. You will be responsible for the $200 deductible not covered by UC SHIP. Psycho-educational testing is billed as neuropsychological testing. If you do not have UC SHIP you are responsible for payment in full for the evaluation.


Records

The Tele-NP may be recorded to ensure accuracy of information for your final written report. I will maintain a record of our appointments in the same way I maintain records of in-person sessions in accordance with my policies.


Informed Consent
This agreement is intended as a supplement to the general informed consent that we agreed to at the outset of our work together and does not amend any of the terms of that agreement.

Your signature below indicates agreement with its terms and conditions.
 
 
 
 
 
 

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