The American Speech-Language-Hearing Association (ASHA) defines telepractice (the act of providing Telehealth services) as "the application of telecommunications technology to the delivery of speech language pathology and audiology professional services at a distance by linking clinician to client or clinician to clinician for assessment, intervention, and/or consultation.” This means that we are able to provide speech therapy services through digital meetings. The speech-language pathologist and the client would join a computer-based session at the designated therapy time, and would work on the same goals as in the office. We term this “teletherapy.”

This mode of service delivery, when implemented correctly, is noted to have equal outcomes to face-to-face interventions.

I understand the following with respect to teletherapy:

• Teletherapy includes treatment using interactive audio, video, or data communications.
• Teletherapy involves the communication of my medical information, both orally and visually.
• I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.
• The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy or consultation is confidential.
• There are risks and consequences from teletherapy, including, but not limited to, the possibility, despite reasonable efforts on the part of Liberty Speech Associates LLC, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
• I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my teletherapy sessions, (2) the information security on my computer, and (3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session.
• Teletherapy has been determined as an appropriate service delivery model for me.

I,   Name*(name of client), hereby agree to engage in teletherapy with Liberty Speech Associates LLC.