• SUFFOLK COUNTY PRESCHOOL

  • CONSENT FOR THE USE OF TELEPRACTICE DURING DECLARED STATE OF EMERGENCY FOR COVID-19

  • AUDIO and VIDEO

  • Instructions: This consent form for the use of Telepractice as a service delivery method for the provision of CPSE services must be completed for each service type authorized for the above referenced student before telepractice services can be initiated. Telepractice as a preschool related service / SEIS delivery method is only available during the declared state of emergency for COVID-19.

    A consent form for the use of Telepractice can be returned by email if the parent/guardian also signs and returns the Suffolk County Parental Approval to Use E-mail to Exchange Personally Identifiable Information. The consent form for the use of Telepractice must be signed and returned prior to the initiation of services. A separate consent form is required for each service.

  • service delivered using Telepractice as a service delivery method

    I understand that Telepractice a preschool related service/SEIS service delivery method is only available during the declared state of emergency for COVID-19 and that my child’s services will be delivered using the method authorized in my child’s IEP after the declared state of emergency.

    I understand that Telepractice means that the CPSE services will be delivered using an audio and video at the same time for the duration of the session.

    My child’s therapist/teacher has explained how the service will be delivered and I further understand my role in assisting with the service delivery.

    I understand that I will have access to all information resulting from the sessions conducted via Telepractice in the same way I would when services are delivered as per the mandated IEP.

  • for immediate initiation of telepractice services

    parent will sign and email the form back to provider within 48 hours of receipt via email or US mail

    SCDOH Preschool Program Covid-19 3/31/2020

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