Instructions: This form must be completed by the teacher/therapist to ensure the continuation of services during the Declared State of Emergency for COVID-19. All fields are required. All information must be completed and must match the appropriate fields on accompanying session notes. The form should be completed WEEKLY, signed by the parent/caregiver who participated in the session. Typed signatures are not acceptable. Please maintain the original document with your files and submit copy with your billing. Teletherapy services must be supported by NYSED guidance and the Governor’s State of Emergency and may not be permitted once the State of Emergency is lifted.