Teletherapy Consent Form

Clinical location
—Please choose an option—Antelope Valley (Palmdale)Los AngelesSan Gabriel Valley (West Covina)Bakersfield

I hereby consent to my/my child’s participation in teletherapy meetings in connection with the following procedure(s) and or service(s) as appropriate to myself/ my child:
Speech therapyOccupational therapy

I confirm that my child and I are currently in the state of CA while attending teletherapy.
Confirmed

I understand that I am responsible for payment of rendered services at the current clinic rate if my funding source does not cover the telehealth meeting.
Confirmed

Nature of teletherapy meeting: During the telehealth meeting, details of patient history, evaluations, assessment results, and chart will be discussed via the teletherapy platform.
I understand

As with any internet-based communication, I understand that risks include the possibility of technological problems which may result in poor quality or disconnection from the virtual visit, as well as a security breach without the appropriate protections. To help mitigate security risks, it is recommended I take steps to protect my personal device and data including using a secure Wi-Fi network with password and using a videoconferencing platform with end-to-end encryption to participate in virtual visits.
I understand

I understand that DV Therapy is not responsible for my device security and acknowledge and knowingly accept the risks of accessing service(s) via virtual technology.
I understand

I understand that I am responsible for the cost of technology associated with receiving therapeutic services through virtual visits (e.g. data/internet plans, personal device).
I understand

Reasonable and appropriate efforts have been made to eliminate/diminish any confidentiality risks associated with the teletherapy meeting, and all existing confidentiality protections under federal and California state law apply to information disclosed during the teletherapy meeting.
I understand

I may withhold, withdraw, or restrict my consent to teletherapy meetings at any time in writing.
I agree with the above statementsI do not agree

I am aware that teletherapy meetings will be conducted using virtual meeting platforms that are HIPAA compliant such as Zoom for Healthcare and video.phone.com.
I agree with the above statementsI do not agree

I understand the potential risks, consequences, and benefits of teletherapy meetings and agree to participate in telehealth meetings for the services listed above.
I understand

I understand that DV Therapy Inc. clinicians will have the same licensure / certification and apply the same standard of care as professionals during an in-person visit.
I understand

I understand that not all clinicians are able to provide virtual visits due to licensure/ practice act restrictions.
I understand

I am aware that my client’s session may be recorded and will be used for training purposes.
I am awareI am not aware

Client Name (required)

Client Date of Birth (required)

Email (required)

I acknowledge receipt of the DV Therapy Client Service Agreement, and agree that I will be responsible for the payment of charges incurred as outlined in the packet. Specifically, I agree to pay for every scheduled appointment, whether I attend, cancel or miss the appointment, if I do not adhere to the guidelines for cancellation. Further, if any collection activities are necessary, I agree to pay all the expenses of such activities, including reasonable attorney’s fees and court costs.

Caregiver’s name: (required)

Caregiver signature: (required)

Date (required)

Accept Terms (required): Click here for our terms

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