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* 1. My child(ren)'s name(s) - please list all household family members who currently receive any therapy services at STEP Therapy Pediatrics:

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* 2. By typing my signature below, I authorize STEP Therapy Pediatrics to utilize TeleHealth services, through a HIPAA-compliant platform called Clock Tree, to provide Occupational Therapy, Physical Therapy, and Speech Therapy (as applicable) to my child(ren), listed above.  TeleHealth is currently being offered as an option during this COVID-19 pandemic to provide ongoing services in the event that a) an individual is quarantined due to symptoms or exposure, b) families are choosing social distancing, c) the physical clinic is mandated to close, d) clinicians are quarantined or choosing isolation.  Despite your clinician providing you with specific detailed instructions during TeleHealth visits, they are unable to ensure safety from remote sites and are relying on family/parent/caregiver to be physically present and within reach of child during all therapeutic activities;  STEP Therapy Pediatrics will not be held responsible for physical injuries during TeleHealth visits.  Benefits of TeleHealth therapy delivery include a) continuity of care, b) maintenance of skills developed through interventions provided during clinic visits, c) increased collaboration and teamwork between clinicians and family members on how to support home carry-over for optimal progress toward treatment goals!
(Name of parent or legal guardian):

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* 3. Today's Date

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