Informed ConsentΔText Input Scroll down on right bar to read the Entire Informed Consent Statement. Informed Consent Howard K. Gurr, Ph.D. Psychologist 2 CORWIN COURT DIX HILLS, NEW YORK 11746 (631) 462-2467 Fax (631) 462-0745 E-Mail: hgurr@drsgurr.com ONLINE THERAPY – INFORMED CONSENT Online Therapy: It is my expectation that you will benefit from online therapy as all or part of your psychotherapy, but there is no guarantee. Therapy is conducted using interactive video. Online based services as care may not be appropriate for your need. If I assess that face to face is more appropriate, I will offer an appointment or provide referrals. Confidentiality: The information disclosed during the course of my therapy is confidential, however there are legal exceptions both mandatory, and permissible, including child, elder, and dependent adult abuse; threats of harm to self or others, or if court ordered. Therapist will take all precautions to ensure online therapy is confidential, but client is informed that transmission could possibly be disturbed or distorted by technical failures, or interrupted or accessed by unauthorized persons. Appointments and Charges for Services: Payment can be made via PayPal or credit/debit cards. Payment arrangements will be discussed prior to the therapy session. Limitations: It is important to realize that online therapy is intended to provide quality information, practical answers to psychological issues, and online therapy for present problems. This service is not intended to provide in-depth psychotherapy as this particular venue is not entirely suited for such purposes. When should I seek traditional mental health treatment rather than internet therapy? 1. If you are having thoughts of harming yourself (e.g. suicidal thoughts) or harming someone else (e.g. violent thoughts toward others) or psychotic symptoms. Please call 911 or 1-800-SUICIDE, which is the National Suicide Hotline. 2. If you are in an abusive or violent relationship. 3. If you have been seriously depressed. 4. If you have serious substance abuse dependence. 5. If you are a minor (under 18 years old). Procedures should we encounter technical difficulties or disruptions in service: It is understood that when communicating by internet or other electronic means, disruptions in service or other technical difficulties will likely occur from time to time. Should a disruption occur at a time of crisis, the patient agrees to immediately phone me at 516 785-3834 By checking off your acceptance of the informed consent and then e-mailing this form: 1. I agree that I reside in the state of New York 2. I agree to participate in online psychotherapy. I have read, understood and comply with the agreed upon policies. I understand and agree with presented fee structure. I AM OVER THE AGE OF 18. I UNDERSTAND THE ABOVE AGREEMENT AND I WISH TO ENGAGE IN ONLINE COUNSELING. I have read the statement above and agree to the Terms and Conditions and Privacy Policy I have read the Patient Services Agreement Statement and I understand my HIPAA rights and regulations, fee structure and cancellation policy.First Name Last Name Email Date / Time Signature Sign Here Submit Form Skip back to main navigation