I, as the parent or legal representative for the above named client or as the client listed above, agree to receive individual therapy, family therapy, and/or an individual diagnostic evaluation, as a telehealth service. I understand that the health care practitioner employed by Behaven Kids is located at either Behaven Kids Omaha, 8922 Cuming Street, Omaha, NE 68114, Behaven Kids Lincoln, 1145 High Street, Lincoln, NE 68502, or Behaven Kids Elkhorn, 20275 Honeysuckle Dr. Elkhorn NE 68022. A telehealth service means that my visit with a practitioner at the distant site will happen by using special audiovisual equipment. This consent is valid for one year for follow-up telehealth services with the practitioner.