Consent to Implement ABA Treatment in Clinic

To protect all clients and staff, I am responsible for disclosing any contagious or communicable illness affecting my loved one. I agree to keep my loved one home and to refrain from bringing them to therapy until they have been cleared to return by a physician.

I understand that behavioral personnel are not medically trained and are not permitted to perform any type of clinical intervention or to administer medication. If my loved one has any specific medical condition, I will disclose it at the beginning of treatment at the center. I am responsible for ensuring that any emergency medication, such as Diastat, is available on site, and that I am present at the time it must be administered, as providers are not permitted to administer medication. I will also disclose all known allergies.

I understand that consistent attendance is essential to treatment progress, and I will make every effort to avoid missing scheduled sessions. Parents and caregivers are expected to communicate with the [Company] in advance regarding any planned missed session, including vacations, illness, or other treatments.

I agree to pick up my loved one on time at the conclusion of each scheduled session. Parents are expected to be present fifteen minutes prior to the conclusion of the scheduled therapy.

Only individuals who are previously authorized and on file will be permitted to pick up my loved one from the center. Authorized individuals must present a picture identification, and the [Company] will, as necessary, make phone contact to confirm authorization before releasing my loved one.

I will disclose to the clinic any legal proceedings related to custody or guardianship so that the appropriate action can be taken.

As the guardian, I am responsible for screening my loved one and ensuring they do not bring any dangerous items to the clinic, such as sharp objects or non-digestible items.

I understand that no person may enter the center with any weapon, including firearms and sharp items.

I understand that services are not personal care in nature. However, toileting accidents may occur and support with toileting may be needed. In those circumstances, I understand and agree that a therapist may assist my loved one, including wiping, as necessary.

I understand that the [Company] reserves the right to install and operate cameras at the clinic center, and that sessions are recorded for safety and clinical monitoring throughout their entire duration. These recordings are used for safety and clinical purposes and are not disclosed except as permitted by law. I understand that, due to the presence of several individuals and the privacy of others, the [Company] may not be legally able to produce a recording when other recipients of services are present.

I understand that the [Company] does not offer transportation as a general benefit. Parents and guardians are solely responsible for bringing their loved one to scheduled sessions and picking them up as scheduled. The [Company] may provide transportation on an individual basis, based on availability.

I understand that other therapists, such as Speech Therapy and Occupational Therapy providers, may be authorized to deliver services at the location, and that those services are coordinated directly with the family. In all cases, services will not be provided concurrently with those disciplines.

I am expected to attend to my loved one's grooming, including keeping their nails short. My loved one should arrive clean, free of valuable items, and ready to be checked in at arrival.