Telehealth Patient Consent Form

Telehealth Patient Consent Form


  1. I hereby consent to my child’s participation in telehealth meetings in connection with the following procedure(s) and or service(s) as appropriate to my child: occupational therapy services, physical therapy services, speech therapy services, multidisciplinary group programs, and other family meetings.

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

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

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

  5. I may withhold, withdraw, or restrict my consent to telehealth meetings at any time in writing.

  6. Telehealth meetings will be conducted using virtual meeting platforms that are HIPAA compliant and are selected by Center for Developing Kids, Inc.

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