1. I understand that my health care provider wishes me to engage in a telehealth consultation.

  2. I understand that video conferencing is not the same as face to face in that I will not be in the same room with the provider. Telehealth is a proven effective technological method for provision of mental health services.

  3. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

  4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

  5. If there is any failure in connectivity, interrupting the normal flow of the session, a phone call will be used to complete the session.

  6. I should treat these sessions just like regular mental health sessions with my provider. I should be on time and adequate clothing is required.

  7. My environment is only able to be controlled by me. I should make sure to ensure I am in a private setting and that there will be no to minimal interruptions. Dynamic Psychometrics encourage you to use an independent room with door.

  8. I understand I will have the opportunity to have a direct conversation with my provider, during which I will have the opportunity to ask questions regarding this procedure.


Telehealth by SimplePractice is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:

  1. Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911 or go to my nearest emergency care unit.

  2. Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical services or advice including, but not limited to, emergency or urgent medical services.

  3. The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any medical advice or care.

  4. I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.

  5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

By signing this form, I certify:

  • That I have read or had this form read and/or had this form explained to me.

  • That I fully understand its contents including the risks and benefits of the procedure(s).

  • That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

Our Values

Our Work Is Heavily Shaped by Our Core Values



We aim at understanding and caring for patients and colleague’s needs and wants, by attentive listening and putting ourselves in people’s shoes.


We want to keep adapting to different situations, with a desire to learn and striving to be better. Learning new trends and technologies in the industry.


Respect everyone we meet and treat them like we want to be treated. Whether it is a colleague or a patient, understanding and respect matter.


We are the experts in our field. Therefore, it is important to have the courage to do what is right knowing that it is for the better good of the person ahead.
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13361 N 56th Street Office B Temple Terrace FL 33617 or Telehealth

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