top of page

Informed Consent for Teletherapy Form

Prior to your appointment
 Please complete this form in order to be able to be seen by one of our qualified employees.


° I understand that a teletherapy consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

° There is evidenced based research supporting pediatric and adult progress during teletherapy with patient supervision and follow through of a home program.

° Caregivers and patients may learn a skill set within a completed session and ask questions on the benefits and challenging during the implementation within the home environment.

° Teletherapy includes evaluation and treatment of a patient’s skills through online assessment, therapeutic exercises, therapeutic activities and caregiver education.

° Though teletherapy does not replace a clinical evaluation or in person therapy session, it may provide patients with face to face interaction, reciprocity through virtual interactive games and activities, caregiver follow through and involvement, and progress when the home program is implemented as demonstrated in the teletherapy session.


I understand that my speech-language, occupational and/or physical therapist wishes me to
engage in a teletherapy consultation.

° My therapist explained to me how the video conferencing technology that will be used to affect such a consultation will work during therapy sessions.

° I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.

° I understand there are clinical limitation to teletherapy such as lost attention and the therapist cannot perform hands on therapeutic physical intervention.

° I understand that my therapist or I can discontinue the teletherapy consult/visit if it appears that the videoconferencing connections are not adequate for the situation.

° I agree to mitigate transmission difficulties (e.g. moving in closer proximity to the wifi source) with my therapist up to three times within a session if wifi is disconnected.

° I understand my child’s appropriateness for teletherapy is at the discretion of the therapist.

° I agree within this session my therapist will bill my insurance as a teletherapy treatment session. If my insurance does not cover the therapy session, I am responsible for the out of pocket costs of a private therapy session ($35.00 for half an hour, $75.00 for an hour session).

°I have had a direct conversation with my therapist, during which I had the opportunity to ask questions in regard to this intervention. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which Iunderstand.


Zoom is the technology service we will use to conduct teletherapy videoconferencing appointments. It is simple to use and there are passwords and a waiting room required to log in. By signing this document, I acknowledge:

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

° Though my provider and I may be in direct, virtual contact through the Teletherapy Service, neither Zoom or my Functional Kids Therapy Center, LLC’ therapist provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.

° The Zoom Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.

° I acknowledge I will be sent a private link, a password and will be admitted to a waiting room to access the treatment session and there will be no video recording for confidentiality purposes.

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

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

By signing and giving verbal consent 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(s).
° That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

Patient/Guardian if patient under 18

bottom of page