Teletherapy Consent Form Teletherapy Consent Please complete this form to consent to teletherapy services. Client Information Client / Child's Name * Client / Child's Date of Birth * I understand that Teletherapy is a mode of delivering health services, including speech and language therapy services, via communication technologies (e.g. Internet or phone) to facilitate diagnosis, consultation, treatment, education, care management, and self-management of an individual’s speech and language needs. By signing this form, I understand and agree to the following: I have a right to confidentiality with regard to my treatment and related communications via teletherapy under the same laws that protect the confidentiality of my treatment information during in-person speech and language therapy. The same mandatory and permissive exceptions to confidentiality outlined in the Practice Policies and Consent to Treatment Form I received from my speech therapist also apply to my teletherapy services. I understand that there are risks associated with participating in teletherapy including, but not limited to, the possibility, despite reasonable efforts and safeguards on the part of my speech therapist, that my speech and language therapy sessions and transmission of my treatment information could be disrupted or distorted by technical failures and/or interrupted or accessed by unauthorized persons, and that the electronic storage of my treatment information could be accessed by unauthorized persons. I understand that miscommunication between myself and my speech therapist may occur via teletherapy. I understand that there is a risk of being overheard by persons near me and that I am responsible for using a location that is private and free from distractions or intrusions. I understand that at the beginning of each teletherapy session my therapist is required to verify my full name and current location. I understand that in some instances teletherapy may not be as effective or provide the same results as in-person speech therapy. I understand that if my therapist believes I would be better served by in-person speech therapy, my therapist will discuss this with me and refer me to in-person services as needed. If such services are not possible because of distance or hardship, I will be referred to other speech therapists who can provide such services. I understand that while teletherapy has been found to be effective in treating a wide range of speech and language issues, there is no guarantee that teletherapy is effective for all individuals. Therefore, I understand that while I may benefit from teletherapy, results cannot be guaranteed or assured. I understand that some teletherapy platforms allow for video or audio recordings and that neither I nor my speech therapist may record the sessions without the other party’s written or verbal permission. The fees charged for teletherapy services are the same as for in person services, and I agree to them. For insurance patients: I have discussed with my speech therapist and agree that my speech therapist will bill my insurance plan for teletherapy and that I will be billed for any portion that is the patient’s responsibility (e.g. co-payments). I have been provided with this information in the Practice Policies and Consent to Treatment Form. I have read and understand the information provided above, have discussed it with my speech therapist, and understand that I have the right to have all my questions regarding this information answered to my satisfaction. Signature Required Your Name * Relationship to Client * Self Parent / Guardian Other Relationship to Client Signature * Clear reCAPTCHA Enter your email to receive a copy of this authorization Entering your email does not add you to any mailing lists. Your information is never shared. Confirm Enter your email to receive a copy of this authorization Submit If you are human, leave this field blank.