I, (Parent/Guardian’s Full Name), consent to have my child’s therapy service delivered using Telehealth as an early intervention service delivery method. I understand that the Telehealth services that my child will be receiving will fulfill the service mandate in my child’s Individualized Family Service Plan (IFSP) and are not being delivered in addition to the home/community-based services that my child is authorized to receive.

I understand that Telehealth, as an early intervention service delivery method, is only available during the declared state of emergency for COVID-19 and that my child’s services will be delivered as authorized in my Child’s IFSP once the state of emergency has been lifted.

I understand that Telehealth means that early intervention therapy services will be delivered using combined audio and video format for the duration of the session. Telehealth does not mean having a telephone call with my child’s therapist/teacher.

I understand that I will have access to all early intervention information resulting from the sessions conducted via Telehealth in the form of Session Notes and Progress Notes if I request them from my child’s Service Coordinator.

I have received a copy of “Your Family Rights in the Early Intervention Program”.

• Speech Therapy
• PT
• OT
• Special Instruction
• Evaluations