Telehealth Informed Consent

Thank you for trusting EBS Children's Institute to work with your child. Please submit the following form granting EBS Children's Institute permission to provide services to your child.
  • I hereby confirm that I give informed consent for the minor or person under my legal guardianship, to have (Occupational Therapy, Physical Therapy and/or Speech Therapy) treatment via video telehealth temporarily. I understand that this is applicable for the short term only and secondary to the COVID-19 outbreak. These services will be provided by EBS Children’s Institute of West Chester. I understand that telehealth video visits offer the same level of clinical intervention and clinically in-depth treatment as face-to-face visits. I agree to provide a space for services that is secure and private, and I understand that EBS Children’s Institute of West Chester will use an electronic platform that meets HIPAA compliance regulations.

    I understand that my child may be seen with a group of students and that other students in the group are also participating from home. Therefore, I recognize that my child may be seen or heard by the family members of the other students.

    I understand that when appropriate, sessions or parts of sessions may be recorded by the therapist for accurate data collection or review for educational and training purposes only. This recording will be viewed only by the therapist and will be deleted when no longer needed. With this knowledge, I agree to allow my child to participate in treatment sessions through telepractice/videoconferencing.