Instructions: A consent form, such as this sample for the use of telehealth as an early intervention service
delivery method, must be completed for each service type authorized for the child including evaluation services
before telehealth services can be initiated. Telehealth as an early intervention service delivery method is only
available during the declared state of emergency for COVID-19. A consent form for the use of telehealth can be returned by email if the parent/guardian also signs and returns the Parental Consent to Use E-mail to Exchange Personally Identifiable Information Form, available here:
The consent form for the use of telehealth must be attached to the child’s integrated case in NYEIS. A separate consent form is required for each early intervention service.