This form must be completed for any client or family member that is borrowing OCP owned equipment/furniture for the purposes of participating in telehealth sessions from home during OCP office closures.  

Client Name:

  :Parent or Guardian Name

Equipment Checked Out: (please list all)

By signing this form, I agree to the following:

• The primary use of this tablet is to participate in telehealth sessions with OCP Therapists.
• The equipment specified above will be used only in the home and will not be taken outside the home, unless otherwise discussed with our primary OCP therapist.
• I will not lend the tablet to anyone, and when using the equipment specified above, I will follow all of OCP’s confidentiality and HIPAA rules.
• If I or my children are using the equipment specified above for any reason outside of telehealth sessions with OCP therapists, I agree to supervise their use at all times and ensure no adult or child are accessing inappropriate sites, applications, or materials on the device(s).
• The protective cover will remain on the tablet at all times.
• I agree to return all OCP equipment specified above in the same condition in which it was borrowed when the OCP office is re-opened or when requested to do so by a manager.