Consent

Consent for Observation

I hereby grant Branched Out Therapy, Inc., and their consultants, contractors or employees to observe in the following setting(s):

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Day Care

Work

School

Other

For the Purpose of:

I understand that during this observation, Branched Out Therapy, Inc., their consultants, their contractors, or their employees may speak to providers, clinicians, teachers, employers, etc. about the client and I thereby grant permission for such discussions.
I am the client, parent or legal guardian of the person named below and have the legal authority to provide consent for observation.

Consent for Services

I authorize Branched Out Therapy, Inc. to render appropriate evaluation and/or therapy services to the client named below in accordance with state and federal laws. I understand that care will be provided by a qualified, licensed, and trained health professional. I recognize, agree and understand that I have the right to refuse treatment or terminate services at any time by Branched Out Therapy, Inc. in writing. In addition, Branched Out Therapy, Inc. may terminate services by notifying me in writing.
I do not give my consent or am withdrawing my consent regarding Branched Out Therapy, Inc. rendering evaluation and therapy services to the client named below.

Consent and Release of Photographs / Videos

I give consent to Branched Out Therapy, Inc. or any party authorized by Branched Out Therapy, Inc. to photograph and/or video record in connection with his/her therapy sessions, for any purpose subject to the therapist’s discretion including but not limited to educational publication, for teaching purposes, and demonstration of progression of his/her skills.
I authorize Branched Out Therapy, Inc. to use pictures of for promotional purposes (ex. brochures, website, etc.)
I acknowledge that I will receive no financial compensation for providing consent since my participation with Branched Out Therapy, Inc. in providing my consent and release is voluntary.
I hereby release Branched Out Therapy, Inc., their contractors, their employees and/or any third parties involved in the creation or publication of Branched Out Therapy, Inc. Publication from any and all liability that may arise in connection with the expressed and implied use of all photographs and videos outlined in this form.
I reserve the right to revoke this agreement at any time. I understand that my right to revoke must be done in writing.
I am the client, parent or legal guardian of the person named below and have the legal authority to execute this consent and release.

Telepractice Consent Form

Telepractice is the delivery of therapy services using distance technology, typically computers, when the clinician and patient/client are not in the same physical location.

Potential Benefits:

Allow for remote therapy services either by choice or when in-person services aren’t available.
Provide education and support to caregivers to foster carryover.
Allow for greater convenience for all parties and reduction of cancellations.

Potential Risks: As with any service, there may be potential risks associated with the use of telepractice.

These risks include, but may not be limited to:

Quality and strength of Internet connection may vary and/or may not be sufficient for high-quality video and audio to allow for effective interaction.
Security protocols of the Internet-based programs could fail, causing a breach of privacy of confidential clinical/medical information.

By Signing This Form, I Understand And Agree With The Following:

The laws that protect the privacy and confidentiality of health information also apply to telepractice. Information obtained during telepractice sessions will not be given to anyone without my consent.
As with any Internet-based communication, I understand that there is a risk of security breach.
I have the right to withhold or withdraw my consent to the use of telepractice.
I have the right to inspect any information obtained and/or recorded through telepractice.
I may expect the anticipated benefits from the use of telepractice, but I understand that no results can be guaranteed.
I have read and understand the information provided above regarding telepractice, and all of my questions have been answered to my satisfaction.
I hereby consent to the use telepractice in the provision of speech therapy services.

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Name Participant or Legal Representative *

Relationship to Client *

Signature of Participant or Legal Representative *

Consent for Observation

Consent for Services

Consent and Release of Photographs / Videos

Telepractice Consent Form

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