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Patient Consent for Telepsychiatry

Thank you for your interest in my services. Please complete the HIPAA-compliant consent form below.

Telepsychiatry is the provision of psychiatric services using a secure online platform and/or telephone, in which the patient and doctor are not in the same location.  Telepsychiatry establishes a formal physician-patient relationship used to maintain regular assessment, diagnostics, therapy and/or medication management.

Potential Benefits of Telepsychiatry

1. Increased accessibility to psychiatric care, eg for patients who may otherwise have limited access to care, eg disabilities and mobility issues;
2. Patient convenience and comfort of receiving care at home or office;
3. Obtaining expertise of a distant specialist;

Potential Risks and Limitations

1. In rare cases, information transmitted may not be sufficient to allow for appropriate decision-making by the doctor, eg poor resolution of audio or video;
2. The doctor may not be able to provide some medical treatments using electronic means nor provide for nor arrange emergency care if needed;
3. In rare instances, security protocols could fail, causing a breach in privacy;
4. Lack of access to complete medical records and/or all information available in a face-to-face visit may result in errors in medical judgment, adverse or allergic drug reactions;
5. Telepsychiatry may not be suitable for certain conditions that require higher levels of care;

The alternative to telepsychiatry is on-site, face-to-face treatment.

Rights and Responsibilities of Doctor and Patient


  1. I understand that Dr. Kardong reserves the right to assess suitability and appropriateness of telepsychiatry candidates for virtual treatment at the outset and during treatment;
  2. I understand that the laws that protect the privacy and confidentiality of medical information also apply to telepsychiatry;
  3. I understand that the secure online platform incorporates software security protocols to protect the confidentiality of information and/or audio/visual data;
  4. I have the right to withdraw my consent to the use of telepsychiatry during the course of my care at any time;
  5. Dr. Kardong has the right to withhold or withdraw her consent for the use of telepsychiatry during the course of my care at any time;
  6. I understand that all rules and regulations which apply to the practice of medicine in the state in which I reside also apply to telepsychiatry.


  1. I will not record any telepsychiatry sessions without the written consent of Dr. Kardong nor will Dr. Kardong record telepsychiatry visits without my consent;
  2. I will inform Dr. Kardong if any other person can hear or see any part of our sessions before the session begins or during the session if the situation changes; Dr. Kardong will do likewise;
  3. I understand that I must be a resident of one of the states where Dr. Kardong is licensed;
  4. I understand that I am fully responsible for the performance of my own technology;
  5. If I live in a state that requires a physical examination prior to prescription of any medications, I agree to arrange this with my primary care provider and release the information to Dr. Kardong;
  6. I agree to inform Dr. Kardong of any other healthcare providers involved in my care;
  7. I agree to provide the name, location and phone number of the patient at the time of each visit.  This is to assist Dr. Kardong in locating alternative means of treatment should an emergency occur;
  8. I understand that, in the event of imminent danger, Dr. Kardong is legally required and ethically bound to report this information to authorities, friends, family, local providers, emergency contact and/or anyone in a position to provide help to you.
  9. I understand that I may expect the anticipated benefits from the use of telepsychiatry in my care but that no results can be guaranteed or assured.

Patient Consent for the Use of Telepsychiatry

I have read and understand the information provided above regarding Telepsychiatry.  I have discussed it with Dr. Kardong and all of my questions have been answered to my satisfaction.
I hereby give my informed consent for the use of Telepsychiatry in my healthcare and authorize her to use Telepsychiatry in the course of my diagnosis and treatment.