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Terms and Policy

Terms of Agreement
Psychotherapy can be a life changing event. Like anything else, you get out of it what you put into it. There are terms to follow in order to provide a secure and completely confidential therapeutic framework of security and foster a desire for your participation.

1. Dr. Marselle will ask you to verify who you are by a government-issued photo ID that you can show him during the initial session or with a Smart Card. You are encouraged to ask questions about the doctor during the video session. Psychologists are licensed, and Dr. Marselle is licensed in California with two profession licenses, Clinical Psychologist, and RN. The board contacts are and

2. Dr. Marselle needs to verify your current location at the time of the session and has another form that requires completion online that has the emergency contacts in your area. Hospital, ambulance service, police, etc. You will have to designate a support person and supply the appropriate contact information in case there is a need to do so. An emergency management system needs to be set up. For example, a lot of people that use TeleMental Health because they live in a rural area, or there is a mental or physical disability that prohibits the ability to get to an emergency responds. Knowing how to reach your first responders is needed, and a plan for your safety.

3. Appropriateness for video conferencing determined at each session by asking if you are alone or who might be able to hear the audio of the meeting. You can have people in the meeting if you need them. They may include spouse, nurse, caregiver, etc. You do not have to sign a release because you imply consent by them being present, but you will be asked in some circumstances to verify that you want a third party present. These are some of the terms for distance treatment. Informed consent need is digitally signed. Dr. Marselle will again go over conditions for an informed consent to be sure you understand reporting laws and confidentiality.

4. Your prescribing and treating medical doctor information are requirements if there are medical issues.

5. Equipment requirements and your ability to problem solve your end of the connection are necessary. You need a computer with a webcam and audio capabilities to hear. Lastly, a good stable web connection. It is disruptive and can be a safety issue if there is a connection loss on either end. A plan of reestablishing contact by telephone will be necessary.

6. Dr. Marselle provides the latest in encryption technology for video sessions and record keeping. His complete technical set up is HIPPA compliant for the regulation of digital data as stated by law. All pertinent digital data is backed up and kept on HIPPA compliant servers located in two different states in case of a disaster at one of the locations. No third party has access to any of your data. All data is encrypted and has encrypted login procedure.

7. Payment and billing information are required.
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Informed Consent
Informed Consent for TeleMental Health Therapy and Services

Robert A. Marselle, Psy. D., RN
27201 Tourney Road, Suite 201
Valencia, California 91355

Welcome to my practice. This document contains valuable information about my professional services and business policies. It also provides summary information about the Health Insurance Portability and Accountability Act (HIPAA). HIPPA is a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex but significant, it is important that you understand them when you sign this document. It will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.


On my TelePsy Website or any other online media: You are never obligated or required to purchase any product or services offered online to obtain professional service. Any written material for purchase or advice given online is not part of professional service. Professional services include only offerings made at and are strictly limited to your account and login. Please, beware that you may have arrived at from a clicking a portal to this site; you have no obligation to register. Registration and creation of an account do not obligate you to obtain professional services. Once you make an appointment and have been notified in person during a video session the professional doctor-patient begins.

Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should know. As your therapist, have corresponding obligations to you. These rights and responsibilities are described in the following sections.

Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, improved skills for managing stress and resolutions to particular problems. But, there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part. To be most successful, you will have to work on issues discuss, outside of sessions.

Appointments will ordinarily be 45-50 minutes in duration, once per week at a time you secure on my confidential web page after you login. Although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours notice. If you miss a session without canceling or cancel with less than 24-hour notice, my policy is to collect the full amount of your session and or co-payment amount. It is important to note that insurance companies do not provide reimbursement for canceled sessions; thus, you will be responsible for the portion of the fee as described above. If it is possible, I will try to find another time to reschedule the appointment. Also, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.

The standard fee for the initial intake is $120.00, and each subsequent session is $100.00. You are responsible for paying for the time of your session. A credit card must make payments for any service. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment. If you do not attend the session and a 24-hour cancelation has not been made, you will be charged a full session amount.

My practice accepts and will bill Medicare for eligible members.

I gladly provide an insurance carrier appropriate invoice for you to submit for reimbursement if you have private insurance coverage.

I am required to keep appropriate records of the psychological services that I provide. Your records are maintained in a secure location. I keep brief records noting that you were here, your reasons for seeking therapy. Also, the goals and progress we set for treatment with your diagnosis and topics we discussed. Your medical, social, and treatment history, records I receive from other providers, copies of documents I send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted or upsetting to untrained readers. For this reason, I recommend that you initially review them with me or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional, which I will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.

1. Everything we discuss will be held confidential. Unless you provide a signed authorization, I will not speak to or correspond with anyone about you.

2. If you choose to break confidentiality in any way (i.e., sending me an e-mail other than through, applying for insurance reimbursement, telling anyone about your therapy), I cannot control or be held liable for the outcome.

3. California law and professional ethics either mandate or permit therapists to break client confidentiality under certain circumstances. Some exceptions to confidentiality include, but are not limited to, the following situations in which there is reasonable suspicion that any of the following has occurred or is occurring now:

* You or your child presents a danger to self or others

* A child or dependent adult is the victim of emotional, sexual or physical abuse, neglect
or unjustified mental suffering

* A dependent adult or any person over the age of 65 years is the victim of physical abuse, emotional abuse, abandonment, forced isolation, fiduciary abuse or neglect

* Psychologists disclose confidential information without the consent of the individual only as mandated by law, or where permitted by law for a valid purpose such as to . . . protect the client/patient, psychologist, or others from harm." In situations when there is cause for serious concern about a client harming someone, the clinician must breach confidentiality to warn the identified victim/third party about imminent danger, the danger must be imminent and the breach of confidentiality should be made to someone who is in a position to reduce the risk of the danger. People who would be appropriate recipients of such information would include the intended victim and law enforcement."

While privacy in therapy is crucial to successful progress, parental involvement can also be essential. It is my policy not to provide treatment to a child under age 13 unless he/she agrees that I can share whatever information I consider necessary with a parent. For children 14 and older, I request an agreement between the client and the parents allowing me to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy. All other communication will require the child's agreement, unless I feel there is a safety concern (see also above section on Confidentiality for exceptions), in which case I will make every effort to notify the child of my intention to disclose information ahead of time and make every effort to handle any objections that are raised.
I am often not immediately available. I am with clients or otherwise unavailable. At these times, you may leave an email message on my confidential TeleMental web page after you login to your account. (Standard email accounts are not secure and I will not respond to emails without a signed consent.) It may take a day or two for non-urgent matters. If, for any number of unseen reasons, you do not hear from me or I am unable to reach you, and you feel you cannot wait for a return contact go to your local hospital emergency room, or call 911 and ask to speak to the mental health worker on call. I will make every attempt to inform you in advance of planned absences.

If you are unhappy with what is happening in therapy, I hope you will speak with me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or with former clients.

Your signature below indicates that you have read this Agreement and the Notice of Privacy Practices and agree to their terms.
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