EI Tele-Eval Consent

Child's First Name:
Child's Last Name:
District:
Date of Birth (MM/DD/YYYY):
Address:
Apt#:
City/Town:
State: New York
Zip Code:

Evaluation Type to be Delivered Using Telehealth: Multi-disciplinary Evaluation
Service Provider Agency: Clinical Associates of the Finger Lakes
Phone #: (585) 924-7207

This form and CAFL's CONSENT TO RELEASE INFORMATION form must be on file in order to begin Telehealth.

I, (Parent/Guardian's Full Name) , consent to have my child’s Evaluation conducted using Telehealth as an approved method.

I understand that Telehealth Evaluations as an approved evaluation method is only available during the declared state of emergency for COVID-19.  

I understand that Telehealth means that the evaluation will be conducted using an audio and/or video method.  

I understand that I will have access to all information resulting from the evaluation(s) conducted via Telehealth in the form written reports. 

By checking this box, I consent to the services and information contained in this form. This represents my legal electronic signature.