Remote Speech Therapy Consent Form
Client Information
Client Name
Date of Birth
Parent/Guardian Name
Phone Number
Email Address
Consent Acknowledgement
I understand that remote (teletherapy) speech therapy sessions will be provided.
I agree to participate in speech therapy using secure audio and/or video technology.
I understand that all client information will be kept confidential as required by law.
I acknowledge I can withdraw my consent at any time by notifying my therapist.
I understand the risks and limitations of teletherapy, including possible technical issues.
Questions or Concerns
If you have any questions or concerns regarding remote speech therapy, please specify:
Consent and Signature
Signature (Type Full Name)
Date