INFORMED CONSENT AGREEMENT

Please read and click to proceed at the bottom of this page. This agreement is intended as an acknowledgment of the below information.

Definitions

This Informed Consent for One-time Evaluation by TelePsychology contains important information focusing on conducting telepsychology using the phone or the Internet. Please read this document carefully, and contact us if you have any questions. Your signing of this document represents an agreement between client and individual provider/esaprovider.com/Provider United LLC (hereafter referred to as “the company”, “us”, “we”).

Purpose

The purpose of this informed consent document is to outline the purpose, scope, limitations, risks, and responsibilities of each party. In addition, it covers fees, associated costs, disclosures, record keeping policy, confidentiality, and Emotional Support Animal (ESA)-specific requirements.

This document establishes a professional relationship between the client and the provider for a one-time evaluation consisting of a telepsychology evaluation for the purposes of determining the suitability of an ESA letter. At the discretion of the evaluating provider, the client may be contacted (via professional email) for the purposes of symptom clarification in order to clarify diagnostic criteria, or for the purposes of establishing a referral to another provider in order to establish treatment for the client.

This evaluation does not constitute an ongoing therapeutic relationship, nor does it constitute treatment.

Benefits and Risks of Teletherapy
Telepsychology as the provision of psychological services using telecommunication technologies, such as video conferencing, email, or telephone. One of the benefits of telepsychology is that the client and clinician can engage in services without being in the same physical location. It is also more convenient and takes less time. Telepsychology, however, requires technical competence on both our parts to be helpful. Although there are benefits of telepsychology, there are some differences between in-person delivery of psychological services and telepsychology, as well as some risks.

Risks to Confidentiality

Because telepsychology evaluations take place outside of the therapist’s private office, there is potential for other people to observe you communicating information via the internet if you are not in a private place during the session. On the company’s end, we will take reasonable steps to ensure your privacy, including ensuring that our telepsychology platform is compliant with the health information provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. However, it is important for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone, computer, or other mobile device. You should participate in telepsychology only while in a room or area where other people are not present and cannot observe your computer screen. In addition, it is recommended that you ensure your wi-fi is password secured and that you completely close out all tabs and windows after you submit your information.

Confidentiality and Issues Related to Technology

There are many ways that technology issues might impact telepsychology. For example, other people might be able to get access to your information, or stored data could be accessed by unauthorized people or companies. However, our website is equipped with various security protocols that will limit this risk to the greatest degree possible. Additionally, we employ updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is always a risk that our electronic communications may be compromised, unsecured, or accessed by others.

Crisis Management and Intervention

This evaluation is not designed to engage in telepsychology with clients who are currently in a crisis situation requiring high levels of support and intervention. By agreeing to this informed consent document, you are endorsing that you are not currently suicidal or homicidal at the time of service.

Associated Costs

You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software to take part in telepsychology. For communication, provider will only use email communication with client in order to clarify diagnostic picture. With client’s consent communicated through email, provider and client may agree to a phone call if this is clinically indicated. You should be aware that the company cannot guarantee the confidentiality of any information communicated by email or wireless device, although company has taken measures to make it as secure as possible.

Fees

Client will be solely responsible for the entire fee of the session. In order to provide the best price to consumer possible, each evaluation will carry one fee: $95 US) to Providers United LLC (depending on choice of product). If additional services are provided (dog training certificate) and additional fee of $60 (US) will be assessed. As ESA letters must be updated yearly, this fee will be repeated on an annual basis, but only after new informed consent and authorization from client (i.e. esaprovider.com and/or Providers United LLC does not participate in “auto-renewal” type of arrangements with clients). Therefore, there is no ongoing contact with the client until client intiates further contact, adn no additional fees. The product purchased will be delievered via email secured with password (date of birth in month/day/year format) in for security purposes.

Refunds

All sales are final upon receipt of goods delivered (i.e. letter or certificate). Exchanges are possible on a case by case basis in the event of misspellings or other errors on the part of the company There is no trial period or discount code available. Customer service contact will be included in the delivery email (wordpress@esaprovder.com). further contact information: Providers United LLC, 5850 San Felipe Street, Suite 500, Houston, TX 77057

Records

The company will maintain electronic records in a secure manner, consistent with all federal and state regulations. This means that your confidential information will be stored for a period of 7 years. Only Providers United LLC will have access to these records, and your information will not be shared, disclosed, or sold to any third party without your written consent.

Disclosures

No client information will be disclosed to third parties without written client consent with the exception of the following:

As mandated reporters, individual providers must disclose information related to:
Child abuse
Elder abuse
Suicidal ideation/threat to self
Homicidal ideation/threat to others

Individual providers/esaprovider.com/Providers United will not disclose or sell your information to any other entity, in the absence of the above situations.

ESA-Specific Information

The telepsychology evaluation is specific only to the animal owner to the extent that they would (or would not) benefit from a Emotional Support Animal. ESA letters shall define only one (1) animal for the client, per evaluation. By signing this agreement, the client certifies that the animal in question is:
1. In good health, absent of any known disease or conditions that would create a danger to the public;
2. Registered with the state, county, city, or municipality in which the animal resides (as applicable)
3. Has received formal obedience training AND/OR is reasonably well-behaved, is able to obey and reliably respond to basic commands, and is housebroken
4. Not aggressive towards humans or other animals. Client acknowledges that any damages inflicted by animal, including but not limited to medical, dental, or any other cost arising out of any type of settlement (whether formally litigated or not) are client’s cost alone.

By signing this agreement, client acknowledges that there is no definitive outcome upon submission of evaluation. That is, there is a possibility the provider will not find it appropriate for the client to be approved for an ESA. There are no refunds issued from a situation arising from a denial of ESA letter by provider, as client is paying for provider’s professional services, not an approved ESA letter.

Further, an approved ESA letter does not release client from any damages that the ESA may cause to property in which they are renting, leasing, or otherwise occupying which they do not own themselves, consistent with the Fair Housing Act.

Consistent with above, an approved ESA letter does not release client from any damages that the ESA may cause to property related to air travel. Furthermore, as airline policies vary with regard to how may and what type of animals are classified as an ESA, client is responsible for reviewing airline-specific ESA definitions, requirements, and protocols prior to engaging in air travel, consistent with the Air Carrier Access Act.

Agreement

By typing your name below and clicking “Next” you certify that you are 18 years of age or older on the date of this evaluation and you indicate agreement with the above terms and conditions.