EI Teletherapy Consent


Early Intervention Teletherapy Consent
Child's First Name: Child's Last Name: Date of Birth (MM/DD/YYYY): Instructions: This consent form, for the use of telehealth as an early intervention service delivery method, must be completed for each service type authorized for the child including evaluation services before telehealth services can be initiated. Telehealth is an early intervention service delivery method available to participant families with their express consent. This consent form for the use of telehealth can be returned by email after the parent/legal guardian also signs and returns the Parental Consent to Use E-mail to Exchange Personally Identifiable Information Form. The consent form for the use of telehealth must be kept in the child’s record. A separate consent form is required for each early intervention service. I, (Parent/Guardian’s Full Name) , consent to have my child’s therapy service delivered using Telehealth as an early intervention service delivery method. I understand that the Telehealth services that my child will be receiving will fulfill the service mandate in my child’s Individualized Family Service Plan (IFSP) and are not being delivered in addition to the home/community-based services that my child is authorized to receive. I understand that Telehealth means that Early Intervention services will be delivered using non-public audio and video at the same time for the duration of the session. I understand that I am entitled to access all early intervention information resulting from provider sessions in the form of Session Notes and Progress Notes on request to my child’s service coordinator. I have received a copy of "Your Family Rights in the Early Intervention Program." (Click Here for Publication) I understand that I have the right to withdraw this consent in writing at any time, for any reason. In the event that I do withdraw consent in writing, my child’s service coordinator will be expected to refrain from scheduling new telehealth sessions for the service listed above, within 7 days of receipt of my notice. Parent Email:
Services Authorized as per IFSP:
Special Instruction Speech-Language Pathology Occupational Therapy Physical Therapy Assistive Technology Teacher of the Deaf
Consent:
By checking this box, I consent to the services and information contained in this form. This represents my legal electronic signature.

Child's First Name:
Child's Last Name:
Date of Birth (MM/DD/YYYY):

Instructions: This consent form, for the use of telehealth as an early intervention service delivery method, must be completed for each service type authorized for the child including evaluation services before telehealth services can be initiated. Telehealth is an early intervention service delivery method available to participant families with their express consent.

This consent form for the use of telehealth can be returned by email after the parent/legal guardian also signs and returns the Parental Consent to Use E-mail to Exchange Personally Identifiable Information Form.

The consent form for the use of telehealth must be kept in the child’s record. A separate consent form is required for each early intervention service.

I, (Parent/Guardian’s Full Name) , consent to have my child’s therapy service delivered using Telehealth as an early intervention service delivery method. I understand that the Telehealth services that my child will be receiving will fulfill the service mandate in my child’s Individualized Family Service Plan (IFSP) and are not being delivered in addition to the home/community-based services that my child is authorized to receive.

I understand that Telehealth means that Early Intervention services will be delivered using non-public audio and video at the same time for the duration of the session.

I understand that I am entitled to access all early intervention information resulting from provider sessions in the form of Session Notes and Progress Notes on request to my child’s service coordinator.

I have received a copy of "Your Family Rights in the Early Intervention Program." (Click Here for Publication)

I understand that I have the right to withdraw this consent in writing at any time, for any reason. In the event that I do withdraw consent in writing, my child’s service coordinator will be expected to refrain from scheduling new telehealth sessions for the service listed above, within 7 days of receipt of my notice.

Parent Email: