⚠️ This is template content and must be reviewed and finalized by the practice's California-licensed attorney and compliance officer before publication. The document signed at intake is the binding version and supersedes anything published here.
1. What Telehealth Means
"Telehealth" refers to the delivery of clinical psychological services from a distance using interactive audio, video, or other electronic communication technology. At Pasadena Clinical Group ("PCG," "we," "us"), telehealth is most often delivered via secure HIPAA-aware video conferencing, with telephone as a backup. This Telehealth Agreement supplements the Informed Consent for Treatment and the HIPAA Notice of Privacy Practices.
2. California Telehealth Law (Bus. & Prof. Code § 2290.5)
California Business and Professions Code § 2290.5 requires that, prior to the delivery of healthcare via telehealth, a clinician licensed in California verbally inform the patient that telehealth services may be used and obtain documented verbal or written consent. By signing this Agreement at intake, you acknowledge that:
- Your clinician has explained the nature of telehealth, its expected benefits, and its limitations;
- You have had the opportunity to ask questions about telehealth and have those questions answered;
- Your consent to telehealth is voluntary and may be withdrawn at any time without affecting your right to receive in-person care, where in-person care is clinically appropriate and available.
3. Your Right to Refuse Telehealth
You may refuse or terminate telehealth at any time. Refusal of telehealth does not change your right to receive future care, although the modality of that care (in-person versus remote) may need to be adjusted based on clinical fit, scheduling, and licensure considerations.
4. Location Requirement
Because our clinicians hold California licensure, you must be physically located in the State of California at the time of every telehealth session. You agree to confirm your physical location at the start of each session if asked. If you plan to be outside California temporarily, please notify your clinician in advance so we can determine whether telehealth can lawfully continue or whether sessions must be paused.
5. Available Hours
Telehealth sessions are available seven (7) days a week within our published hours of 7:00am to 9:00pm Pacific Time. Specific session days and times are scheduled in advance with your clinician.
6. Technology Requirements
You agree to use the following to participate in telehealth:
- A device with a camera, microphone, and stable internet connection (recommended: at least 5 Mbps download / 1 Mbps upload);
- An updated, supported browser or telehealth application as directed by your clinician;
- A private, secure, and quiet physical space free from interruption.
Pasadena Clinical Group uses HIPAA-aware video conferencing platforms governed by Business Associate Agreements. Despite reasonable safeguards, no electronic transmission can be guaranteed to be 100% secure. By participating in telehealth, you acknowledge and accept the residual risks inherent in any internet-based communication.
7. Limitations of Telehealth
Telehealth has limitations. These can include:
- Inability to fully observe non-verbal communication (e.g., posture, environment, full body language);
- Disruptions due to internet, audio, or video failure;
- Reduced ability to respond rapidly in the event of an in-session clinical emergency;
- Limitations on certain assessments and exposure-based interventions that may be more effective in person.
Your clinician will discuss with you when telehealth is clinically appropriate and when in-person care or a referral elsewhere is recommended.
8. Telehealth Is Not for Emergencies
Pasadena Clinical Group is an outpatient practice and does not provide 24/7 emergency or crisis services. Telehealth is not appropriate for behavioral-health emergencies. If you are experiencing a mental-health crisis or are at risk of harm to yourself or others:
- Call or text 988 (Suicide & Crisis Lifeline);
- Call 911;
- Or go to your nearest emergency room.
You may also contact the Los Angeles County Department of Mental Health 24/7 Help Line at (800) 854-7771.
9. Emergency Procedures During Telehealth
At intake, you will be asked to provide:
- The full street address at which you ordinarily attend telehealth sessions;
- An emergency contact and their phone number; and
- The name and address of the nearest emergency room.
If your clinician determines that you are at imminent risk during a session, your clinician may contact emergency services at your physical location, contact your designated emergency contact, or take other reasonable steps to support your safety.
10. Recording Prohibition
Telehealth sessions are not routinely recorded. You agree not to record any telehealth session, in whole or in part, without prior written consent from your clinician. Your clinician likewise will not record sessions without your written consent. Unauthorized recording of psychotherapy sessions may violate California penal and civil law (including Cal. Penal Code §§ 631 and 632), professional ethics codes, and this Agreement.
11. Confidentiality and Privacy
The same confidentiality protections that apply to in-person sessions apply to telehealth sessions, including HIPAA, the California Confidentiality of Medical Information Act (CMIA, Cal. Civ. Code § 56 et seq.), and applicable professional ethics codes. You can support that confidentiality by:
- Joining sessions from a private space where others cannot overhear;
- Using headphones if practical;
- Not joining sessions from public Wi-Fi networks where avoidable;
- Logging out of devices and platforms when sessions end.
12. Insurance and Payment
Most California payers reimburse telehealth services on parity with in-person services, though specific coverage varies by plan and benefit. Co-payments, co-insurance, and deductibles for telehealth are due at the time of service consistent with our Office Policies. Please contact our care coordinator for benefits verification.
13. Trainee and Supervision Considerations
If your clinician is a doctoral trainee, supervision may include review of session content and, with your written consent, recorded segments. Your clinician will explain supervision arrangements before you begin care.
14. When We May Recommend Stopping Telehealth
Your clinician may recommend that telehealth be paused, modified, or discontinued in favor of in-person care or referral if, in their clinical judgment, telehealth is no longer appropriate. Reasons may include severity of presenting symptoms, technology disruptions that compromise care, geographic considerations, or clinical needs better served by in-person assessment.
15. Acknowledgment
By accepting this Agreement at intake, you acknowledge that you have read and understand it; that you have had the opportunity to ask questions; and that you consent to receive psychotherapy services from Pasadena Clinical Group via telehealth subject to the terms above.
16. Contact
Pasadena Clinical Group
301 N. Lake Ave, STE 600
Pasadena, CA 91101
Phone: 626-354-6440
Email: office@pasadenaclinicalgroup.com
This document is sample/template language. Final published versions should be reviewed by California-licensed counsel and the practice's compliance officer.