Fairmount Speech and Swallowing Therapy

(215) 645-2699

contact@fairmountspeech.com

• I understand that teletherapy involves the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to receiving health care services via teletherapy over secure video conferencing platform and other communication and electronic tools.
• I understand that the laws that protect privacy and the confidentiality of my medical information also apply to teletherapy. 
• I understand that while teletherapy treatment has been found to be effective in treating a wide range of disorders, there is no guarantee that all treatment of all clients will be effective. 
• I understand that there are potential risks involving technology, including but not limited to: Internet interruptions, and technical difficulties which may result in service interruption and that Fairmount Speech and Swallowing Therapy is not responsible for any technical problems and do not guarantee that services will be available or work as expected.
• I understand that I am responsible for information security on my computer and in my own physical location. 
• I understand that either me or my Speech-Language Pathologist can discontinue the teletherapy services if it is felt that this type of service delivery does not benefit my needs or for any other reason.
• I have read and understand the information provided above regarding teletherapy, have discussed it with my Speech-Language Pathologist and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of teletherapy.

By signing I confirm that I have read, understand and agree to all of the above.