The purpose of this form is to provide information to you about, and to obtain your consent to participate in, a telehealth consultation with your speech pathologist, occupational therapist and / or psychologist (from here on referred to as “clinician”).

Telehealth is the use of telecommunication to provide allied health services to clients. The clinician typically uses videoconferencing to administer client sessions in real-time but may utilise other formats, such as email, for related communication. Telehealth is sometimes referred to as telepractice, telerehabilitation, or telespeech.

A telehealth consultation usually involves some or all of the following: • Your clinician will discuss your health and your health history with you and, where appropriate, will offer information and advice. • You may bring a support person with you, as you might in a face to face consultation. • If you attend a health service to participate in a telehealth consultation, other health professionals may be present and may need to examine you according to your clinician’s instructions. • A technical support person might be present for part of the consultation to assist with technical issues. • You are not permitted to video or audio record the consultation, unless your clinician gives you permission to do so.

Telehealth might: • Improve access to allied health services • Reduce your need for travel • Decrease exposure to infectious disease

Telehealth might: • Be negatively impacted by technical problems, such as delays due to technology failures. • Not offer the same visual and sound quality for observations and modelling • Require someone onsite with you to support the clinician • Not feel the same as an onsite session • Not achieve everything that is required and therefore require another telehealth consultation or a face to face consultation. • Include practices and procedures that are not as well understood in a telehealth setting as they are onsite • Increase exposure to privacy and digital security risks. (See next section.)

This practice is subject to the Privacy Act 1988 and must comply with obligations related to the collection, use and disclosure of personal information, including through telehealth. The clinician must maintain confidentiality and privacy standards during sessions, and in creating, keeping and transmitting records. At times, audio and video recordings of sessions may be taken to support the clinician’s work, as might occur in a face to face consultation. You will be informed before a recording takes place and can refuse to be recorded for any reason. The clinician will inform you of the reason for the recording and how it will be stored. While the clinician is obligated to meet standards to protect your privacy and security, telecommunication, including videoconference, may increase exposure to hacking and other online risks; as with all online activities, there is no guarantee of complete privacy and security protection. You may decrease the risk by using a secure internet connection, meeting with the clinician from a private location, and only communicating using secure channels.

There are a few important principles related to informed consent: • You must be given relevant information. Ask the clinician if you have questions about telehealth and the services offered. • You have the right to understand the information. Ask the clinician if you do not understand. • You have the right to choose. If you do not agree to telehealth, you may refuse to participate. You may agree to or refuse specific activities and procedures. • You have the right to stop using telehealth anytime. You can change your mind about telehealth or a specific activity or procedure, even in the middle of a session. • You can agree or refuse in writing or verbally. You may give your consent using the form below. You may also give consent or change your mind by telling the clinician. Consent and refusal that you give verbally will be documented by the clinician. • You can ask about alternatives to telehealth. If you refuse or change your mind about telehealth services, your clinician will discuss any other options with you. The clinician may or may not be able to offer alternative services.

Please check all that apply: