Teletherapy consent

Authorize speech-language therapy by video when it serves the plan. Same 24-hour cancellation courtesy. Fees are named before care begins.

Teletherapy

Teletherapy is speech-language therapy by a secure video visit when it serves the plan. It is not a walk-in clinic and not a promise that every hour can be in person.

Client name *Client / guardian name *I understand

The session happens by video at a scheduled timeI will join from a reasonably private place and will say if someone else can hearIf the connection drops, I will wait and try again, or call / text 773-457-1204Emergency help is local to me; R.O.S.E. is not an emergency lineThe same 24-hour cancellation courtesy appliesTherapy fees are named before care begins; this consent is not a session-rate quoteTeletherapy does not replace a physician or promise a health plan will pay

Usual city / state for the visitSignature *Date *

Drafts stay on this device only. Printing creates a PDF through your browser. Emailing opens your mail app with a text summary. These templates support care and documentation; they are not a substitute for legal review of privacy or consent language.

Every journey begins with hope.
Every bloom begins with R.O.S.E.

Every bloom begins with R.O.S.E.