Informed Consent for Teletherapy

1. I understand that my speech- language pathologist wishes me to engage in treatment via telehealth.

2. My speech-language pathologist explained to me how the video conferencing technology that will be used to affect such treatment will work during therapy sessions.

3. I understand that a telehealth session has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth visit if it is felt that the videoconferencing connections are not adequate for the situation.

5. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me.

Zoom is the platform we will use to conduct telehealth videoconferencing appointments. It i simple to use and all log-in information will be provided in advance of the telehealth visit. By signing this document, I acknowledge:

1. Zoom is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.

2. Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither Zoom nor Talk Play Learn Speech Therapy provides emergency or urgent medical services.

3. Zoom facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice, or care.

4. I do not assume that my provider has access to any or all of the technical information for Zoom – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information for Zoom.

5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

By signing this form, I certify:

• That I have read or had this form read and/or had this form explained to me .
• That I fully understand its contents including the risks and benefits of the procedure.
• That I have been given ample opportunity to ask questions and that any questions  have been answered to my satisfaction. 
• That my provider informed me that based on their professional judgement, this  modality ( teletherapy ) appears to be suitable for the provision of speech therapy for me/my child.