DE Consent for Telehealth

Consent for the Use of Telehealth for Early Intervention Services

Parent or Guardian First Name*
Parent or Guardian Last Name*
Phone Number*
Email Address*
Family's Home Address
Street Address Address Line 2 City State ZIP Code
Child's Name:*
Child's Date of Birth:*
MM slash DD slash YYYY
Thank you for your interest in using telehealth as an early intervention service delivery method for you and your child. Delaware’s Birth to Three Program requires that consent be signed prior to the start of services delivered via telehealth. Please read the consent information below. You will be provided a copy of this form for your records.

Parent(s)/Guardian Acknowledgment and Statement of Consent:
1. I consent to the delivery of EI services by virtual visits over a computer, tablet, or smart phone between Delaware’s EI service providers and my child and family.
2. I understand that all the parent rights, as described in the Guide to Family Rights, will be provided.
3. I understand the need for security and that I take steps to protect my own personal device and information including using a secure Wi-Fi network with a password and using the link for the videoconferencing platform that the provider sends me when I participate in virtual visits.
4. I understand that I am responsible for the cost of my personal equipment and the technology (e.g. data/internet plans, personal device) used by me for the visits.
5. I understand that the use of telehealth is a temporary strategy to providing EI services during the current COVID-19 health crisis and will be terminated once the State public health emergency is lifted.
Signature of EI Professional:
To be signed after form is submitted
Date:
MM slash DD slash YYYY