Clinical Associates
of the Finger Lakes

PSE Teletherapy Consent

Pre-school Teletherapy Consent

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

I, (Parent/Guardian’s Full Name) , consent to have my child’s 

(Check all service(s) that apply):

Special Education
Speech-Language Pathology
Occupational Therapy
Physical Therapy
Teacher of the Deaf
Assistive Technology

service(s) delivered using teletherapy as a service delivery method.   I understand that the teletherapy services that my child will be receiving will fulfill the service mandate in my child’s Individualized Education Plan (IEP) and are not being delivered in addition to the home/community-based services that my child is authorized to receive.

I understand that there are potential risks involving technology, including but not limited to:  Internet interruptions, and technical difficulties.  I understand that technical difficulties with hardware, software, and internet connection may result in service interruption and that the health care provider is not responsible for any technical problems and does not guarantee that services will be available or work as expected.

I understand that teletherapy means that services must be delivered using non-public audio and video at the same time for the duration of the session. I understand that a caregiver must participate consistently throughout the entire 30 minute session (or duration identified on IEP) with my child. Teletherapy does not mean having a telephone call with my child’s therapist/teacher.  I understand that I may request session notes from my child’s therapist.

Provider Policy:

The CPSE provider will follow the guidelines for providing virtual or teletherapy services in order to ensure appropriate delivery and continuum of care:

  • Competence must be obtained prior to offering services and continually reassessed to ensure the provider is servicing clients legally and ethically according to state laws, and individual
  • Services shall be provided in a private, HIPAA and FERPA compliant space without risk of breach of protected patient information for both the service provider and the client.
  • Technology devices must be accessible, with as substantial ease of use as for a person without physical or cognitive challenges. The client/facilitator must be able to interact appropriately, and services and devices must be compliant with the Individuals with Disabilities Act (IDEA) for students served under this law.
  • If clinical expertise demonstrates that virtual services are no longer appropriate, due to progress, lack of progress, limitations of virtual services, or any other circumstance, the virtual service provider shall cease services.
  • Documentation and record keeping must adhere to all federal, state, local and/or district Providers must note that the therapy services were provided virtually.
  • The therapy services must be a minimum of 30 minutes or the length identified on the IEP.

Parent Email:

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