INFORMED CONSENT FOR TELETHERAPY SERVICES

Go 2 Speech, LLC is proud to offer secure online therapy services delivered by our experienced, nationally certified speech-language pathologists. Please visit Go2speech.com or call 954-882-4312 to learn more about the engaging teletherapy services we provide for children at school and at home.

All sections of this form must be completed prior to your child's first session with Go 2 Speech.

Child's Name *

Child's School *

Child's Date of Birth *

Person Completing the Form *

Relationship to Child *

I confirm that I have legal custody of my child, named above, and am authorized to access their private medical information (HIPAA) and educational records (FERPA), specifically as related to speech-language services provided by Go 2 Speech. *

HIPAA (Health Insurance Portability and Accountability Act of 1996) is United States legislation that provides data privacy and security provisions for safeguarding medical information.

FERPA (Family Educational Rights and Privacy Act of 1974) is United States legislation that protects the privacy of students' personally identifiable information.

I understand that my child’s individual or small group teletherapy sessions will be guided by their Individual Education Plan (IEP). Go 2 Speech makes no guarantee that participation in speech-language therapy will result in any specific outcome. Every reasonable effort will be made to provide effective interventions using evidence-based practices. *

Students receiving speech-language services at school will be supervised by a designated staff member. I understand that students receiving teletherapy at home must be supervised by a parent or guardian, to comply with state and federal laws. Go 2 Speech cannot control the behavior of students, staff members, parents/guardians, nor other observers, and accepts no responsibility for their actions. *

I hereby give consent for my child to participate in speech-language teletherapy sessions delivered by a nationally certified, state licensed Go 2 Speech therapist. I understand that I may revoke consent at any time by notifying my child’s school administrator or Go 2 Speech in writing. *

I have read and understand each part of this agreement and am authorized to execute this agreement on behalf of my child, named above.

Parent/Guardian Name *

Phone Number *

Email *

Date *

Signature *

Please use the mouse to sign your name. Then, click below to submit this form.

Informed Consent For Teletherapy Services

954-882-4312

hello@go2speech.com