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Thank you for choosing us for your telehealth care. Consent for telehealth services

is an important aspect of remote healthcare delivery to ensure both clients and

providers are on the same page regarding the treatment being provided. We want

you to understand your rights and responsibilities while receiving care from us.

If you have any questions about this form, please feel free to reach out at any time.

If you are a parent/legally-authorized representative of a child, please read this

agreement with the understanding that “I” and “me” means the child.

1. Consent for Treatment: I consent to telehealth care performed by the BCBA and

the Paraprofessional at Shine ABA Solutions. These services may include

assessment, intervention, consultation, and training related to behavior analysis

and skill development. I understand that these services will be provided through

video calls and other telecommunication technologies. I understand that I have

the option to refuse the delivery of health care services by telehealth at any

time without affecting my right to future care or treatment, and without risking

the loss or withdrawal of any benefits to which I would otherwise be entitled.

2. Consent for Telehealth Services:

Telehealth involves transmission of video. I understand that:

● I will be informed of any other people who are present at either end of the

telehealth encounter, and have the right to exclude anyone from either location.

● All confidentiality protections required by law or regulation will apply to my


● I have the right to refuse or stop participation in telehealth services at any

time and request alternate services such as an in-person service. However, I

understand that equivalent in-person services might not be available at the

same location or time as telehealth services.

● If I do not want to receive services by telehealth, it will not affect my right

to future care or treatment, or any insurance/ program benefits to which I would

otherwise be entitled.

3. Records and Release of Information: Transmitted Data may become part of my

medical record. Data will not be transmitted to people outside my health care

team except as described below, and/or if I provide additional written consent.

● I will have access to all of the information in my medical record resulting

from the telehealth services that I would have for a similar in-person visit, as

provided by federal and state law.


905 -07 West Beech Street, Long Beach NY 11561

2307 Coney Island Avenue 2nd floor, Brooklyn, NY 11223

Tel: (516)-615-2211


●The Providers may use or disclose my health information for treatment, continuity

of care, payment, or internal operations, or when required by law or regulation in

certain unique situations.

●All releases of information are subject to the same laws and regulations as in-

person care.


4. Benefits and Risks:

I acknowledge that the benefits of ABA telehealth services include convenience,

reduced travel, and the ability to receive ABA services in the comfort of my own

home. I also understand that there may be risks and limitations associated with

telehealth, including potential technical issues, interruptions in communication, and

limitations in direct physical interaction for assessment.

5. Privacy and Security:

I understand that my personal and health information will be collected and stored in

compliance with applicable privacy laws. I acknowledge that appropriate security

measures will be in place to protect the confidentiality of our telehealth sessions.

6. Informed Consent:

I have been provided with an explanation of the proposed ABA treatment plan and

goals that will be addressed through telehealth. I have had the opportunity to ask

questions and seek clarifications regarding the ABA telehealth services.

Thanks for submitting!

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