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English to Khmer (Central): English_Worcester Speech Teletherapy Form General field: Medical Detailed field: Medical: Health Care
Source text - English SPEECH AND LANGUAGE TELETHERAPY CONSENT FORM
During the school closure, Worcester can continue providing remote speech-language pathology
therapy through digital “teletherapy” sessions using Zoom or Google Classroom , whereby the
SLP and student meet via a video/audio telecommunication session at the designated time, and/or
via stored and recorded sessions. Teletherapy will be tailored to and coordinated with each student
Before implementing teletherapy for your student, the District is sending you this form to provide
you with important information regarding teletherapy services and to request your consent to use
teletherapy. Please note that due to licensing and ethical requirements, teletherapy may not be
available to your student without your informed consent. As such, we ask that you please carefully
read this form, sign it, and return the signed form to the ______________________via email at
[EMAIL ADDRESS] or mail at [MAILING ADDRESS] or ____________________.
1. By signing this form, you consent to your student’s participation in teletherapy as described
herein. Agreement to use teletherapy shall not in any way limit the applicability of any
other applicable policy or agreement, including without limitation the District’s Acceptable
2. The laws that apply to services to students in a school setting also apply to teletherapy.
The District has attempted in good faith to ensure that all teletherapy is controlled and
managed for security and confidentiality in compliance with FERPA, CIPA, COPPA, and
HIPAA guidelines, and all other applicable state and federal laws. However, despite efforts
to protect their privacy and confidentiality, breaches may occur. To aid in maintaining the
security of your student’s teletherapy, please do not share any information regarding your
session, such as the meeting ID, link, passcode, video/audio service, service provider, date,
or time, with any third party, and ensure that no third party is able to physically observe
the student during teletherapy.
3. To maximize the effectiveness of teletherapy, students should be in a private space, free
from distractions or intrusions, unless the presence of another individual is requested to
facilitate service delivery.
4. If your student receives group services under regular circumstances, teletherapy may also
include group services. As such, any information conveyed during group teletherapy
may be observed by other students, parents/guardians, and other individuals who may be
present in a participant’s location. All students, parents/guardians, and other individuals
must respect and keep confidential any information regarding other students that may be
shared, revealed, observed, or otherwise discovered during teletherapy.
5. Your service provider may determine that teletherapy sessions should be recorded to aid in
the delivery of such services. In the event your service provider determines that recording
is appropriate for your student, you will be specifically notified prior to the start of the
recording. By participating in the teletherapy session after notification, you will be deemed
to have consented to the recording.
6. Teletherapy is being offered to your student in good faith based upon a determination that
teletherapy may be appropriate given the current circumstances. However, teletherapy may
not be effective for every student. During the period of teletherapy, the service provider
will evaluate the effectiveness of services provided by teletherapy and measure their
outcomes. If your student’s service provider determines that teletherapy is not effective
for your student, you will be contacted to explore potential alternatives.
7. You have the right to refuse or discontinue teletherapy services at any time. In the event
you do not wish to use teletherapy, please contact the District to explore potential
alternatives. However, please be advised that these options may be severely limited due to
restrictions under applicable laws and risks posed by the ongoing pandemic.
By signing below, parent/guardian, on your own behalf and on behalf of your student, and student,
if of the age of majority, each acknowledge and agree that you have had full opportunity to read
and review this Teletherapy Consent Form and that you understand, and agree to the terms.
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