Telepractice Consent Form

Telepractice is the delivery of therapy services using distance technology, typically computers, when the clinician and patient/client are not in the same physical location.

Potential Benefits:

Allow for remote therapy services either by choice or when in person services aren’t available.
Provide education and support to caregivers to foster carryover.
Allow for greater convenience for all parties and reduction of cancellations.

Potential Risks: As with any service, there may be potential risks associated with the use of telepractice.

These risks include, but may not be limited to:

Quality and strength of Internet connection may vary and/or may not be sufficient for high-quality video and audio to allow for effective interaction.
Security protocols of the Internet-based programs could fail, causing a breach of privacy of confidential clinical/medical information.

By signing this form, I understand and agree with the following:

The laws that protect the privacy and confidentiality of health information also apply to telepractice. Information obtained during telepractice sessions will not be given to anyone without my consent. As with any Internet-based communication, I understand that there is a risk of security breach. I have the right to withhold or withdraw my consent to the use of telepractice. I have the right to inspect any information obtained and/or recorded through telepractice. I may expect the anticipated benefits from the use of telepractice, but I understand that no results can be guaranteed. I have read and understand the information provided above regarding telepractice, and all of my questions have been answered to my satisfaction. I hereby consent to the use telepractice in the provision of speech therapy services.

Name of Client

Date

Name of Parent / Caregiver Signature of Witness

Date