Tele-Psych

Your Full Name(required)

Your Email(required)

Please check all that apply

I am able to have a private space, free from other people, for at least 30 minutes. I am able to have space free from distraction for at least 30 minutes I am willing to place a credit card or debit card or HSA card on file I have reliable access to a computer with a camera and microphone I have reliable access to a smart phone with a camera and microphone I have reliable access to high-speed internet I understand how to use FaceTime I understand how to use Skype and have the application installed on my phone I understand how to use Zoom web conferencing

Location where Tele-Health visits will be done (e.g. at home in my bedroom)(required)

I give permission for my clinician at Oak Park Behavioral Medicine to contact the following person as my Emergency Contact in the event I am in imminent threat of harm to myself or other people.(required)

Full Name of Emergency Contact(required)

Telephone Number of Emergency Contact(required)

Nearest Emergency Room to Me (Name of Hospital)(required)