Therapeutic LINK for Children 6167 W. Quaker Street - Orchard Park, NY 14127

Philosophy Statement...

Since 1999, we have been committed to making a difference in the lives of children we serve, while celebrating the diversity and unique individualized nature of every child and family.

Parental Consent to Participate in Telehealth & Use E-mail in Electronic Exchanges

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”.

Child Information
Services Requested:
  • Speech Therapy
  • PT
  • OT
  • Special Instruction
  • Evaluations
  • By checking this box, I consent to the services and information contained in this form. This represents my legal electronic signature.