Telehealth Psychotherapy Addendum

Date of Service: [date]

Session Time: [start time – stop time / duration; include time zone if patient and clinician are in different zones]

Modality: [synchronous audio-video / audio-only / mixed]

Platform: [platform name / telephone]

(This addendum documents telehealth operational, legal, and safety elements only. Do not include psychotherapy process content, mental status exam, or clinical formulation.)

Location & Identity Verification

Patient Location: [setting type and full address sufficient for emergency dispatch; explicitly confirmed by patient today]

Clinician Location: [city, state]

Jurisdiction Confirmed: [yes / no] (If no, document that the session did not proceed and record alternative action taken.)

Identity Verified: [method used, e.g., two identifiers / photo ID / established patient recognition]

(If patient refused to provide location or identity could not be verified, document the refusal and that the session was not conducted.)

Consent, Privacy & Participants

Telehealth Consent: [on file (date: [date]) and reaffirmed today / verbal consent obtained today]

Patient Environment: [private / not private with mitigation: [describe] / session deferred due to lack of privacy]

Safe to Speak: [yes / no / uncertain] (If no or uncertain, document mitigation or deferral.)

Others Present: [patient alone / names and relationships of others present with patient consent noted]

Audio-Only Rationale: [patient preference / inability to use video / connectivity limitations / other: [describe]] (Include only if audio-only modality was used.)

Emergency Plan

Emergency Contact: [name], [relationship], [phone] (Patient consents to contact: [yes / no])

Disconnection Plan Confirmed: [yes / no] (Standard plan: attempt reconnect, call patient at verified number, contact emergency contact or dispatch services to confirmed location if safety concern and unable to reach.)

(If patient refuses to provide an emergency contact, document the refusal and note that emergency services may still be dispatched using the confirmed location.)

Technology & Clinical Adequacy

[No significant technology limitations; session clinically adequate via chosen modality.] (Use this statement if no issues occurred.)

[Technology issues: [describe issue]. Impact on clinical assessment: [none / describe what was affected]. Mitigation: [action taken]. Follow-up: [continue telehealth / in-person recommended / reschedule].] (Use this format if issues occurred; specify which clinical aspects were limited if applicable.)

Attestation

[Attestation statement confirming: modality used; patient location confirmed; identity verified; telehealth consent obtained or reaffirmed; privacy and environment reviewed; emergency plan reviewed; technology limitations none identified or addressed as documented.]

(Write as one concise first-person statement, e.g., "I conducted this session via [modality]; confirmed patient location and identity; obtained telehealth consent; reviewed privacy and emergency plan; no technology limitations identified.")

Clinician Signature: [name, credentials, date/time signed]

(If the session could not proceed due to safety or compliance barriers, document what occurred, why, and any alternatives or next steps taken.)