Client / Guardian Consent for Treatment

Participation in Behavior Analysis services at the Company is voluntary. I have chosen to receive or continue receiving these services based on recommendations from my physician and treatment team.

I acknowledge that it is necessary to obtain client / parental consent before services begin. I am entitled to receive comprehensive information about the interventions and procedures that will be carried out, and I may engage in discussions with the provider for clarification before granting consent. I am entitled to obtain a copy of the individualized Behavior Support Plan (BSP), and I retain the right to withdraw my consent at any time without penalty.

By consenting to receive services from the Company, I authorize my insurance carrier to provide insurance benefits to the Company. I agree to the release of all necessary medical information required for billing and administrative purposes. I accept personal responsibility for deductions, coinsurance, and payment disallowances, and I understand that I am financially liable for any services not covered by my insurance.

To attain optimal clinical outcomes, active participation by parents and caregivers is essential. The effectiveness of therapy relies in part on caregivers acquiring the skills needed for behavior management. I am expected to communicate treatment requirements, share up-to-date medical information that may impact treatment, actively engage in scheduled sessions, and provide feedback to the provider and the agency.

The Company maintains strict confidentiality of records. Only authorized agency personnel can access client information electronically and / or physically. Personal information will not be released without my prior written authorization, except in cases authorized by law (such as abuse, neglect, imminent danger to life, or by court order). I have the right to request restrictions on how protected health information about me is used or disclosed for treatment, payment, or healthcare operations.

I am aware that the nature of services implies the presence of undesired behaviors that may be challenging to manage. The Behavior Support Plan (BSP) describes specific crisis procedures detailing what to do when undesired behaviors escalate. If staff are unable to manage the behavior safely, 911 will be called and pertinent parties will be informed and notified.

Individuals with behavioral challenges have the same rights as everyone else. I acknowledge that I have been provided a physical copy of the Bill of Rights (attached) and that its contents have been explained to me.

Behavior Analysis therapy services cannot be provided concurrently with other services such as Personal Care Services, Speech Therapy, Occupational Therapy, or any services or occupations where the provider does not have direct involvement with the recipient. I affirm, in good faith and to the best of my knowledge, that I am not currently receiving services from any other Behavior Analysis agency and do not have an active case with any other provider. If I decide to receive services from another provider, I will promptly terminate services at the Company. Exceptions may be granted by the Clinical Director where medical necessity is demonstrated.

As the caregiver, I will inform the Company of any necessary changes related to services, including scheduling, addresses, phone numbers, relevant medical information, and other relevant updates.

Under no circumstances should I leave my loved one unattended during therapy sessions. I retain the right to cancel a session if I am unable to attend or be present. Company providers cannot be left alone with a client. Providers are strictly prohibited from providing transportation to clients or family members in their personal vehicles. Any dual relationship that arises during the provision of services must be promptly disclosed for appropriate action; for example, a provider cannot serve as both the client's RBT and a family member simultaneously.

I attest that I have received detailed information and specific instructions on reporting abuse, neglect, and exploitation of children and vulnerable adults. In accordance with Chapter 415, Florida Statutes, I understand that reports must be made to the Florida Abuse Hotline. The Company representative has explained, in my language of choice, how to recognize physical, behavioral, and environmental indicators of abuse, neglect, and exploitation. I have been instructed on how to report suspected abuse by calling 1-800-962-2873 or 1-800-96-ABUSE, including the information needed for the report, and on how to report life-threatening emergencies to 911. I understand that all Company providers are mandated reporters, and that the Company has instructed every provider to report any relevant information they observe in the course of providing services.

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. I am responsible for ensuring that any medication that needs to be administered during the course of a session is administered by me, and that I provide the medication myself. In case of emergency, 911 will be called, 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 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.

When services are provided at the clinic center, 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.

When services are provided at the clinic center, only individuals who are previously authorized and on file will be permitted to pick up my loved one. 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 understand that the [Company] reserves the right to install and operate video recording at the clinic center for safety and monitoring purposes. 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 I have the right to express concerns, complaints, or grievances regarding the services provided by the [Company]. I acknowledge that the agency maintains a Grievance Procedure designed to address and resolve concerns in a timely, fair, and confidential manner. If I have a complaint regarding services, staff, scheduling, communication, quality of care, or any other matter related to services, I may submit my grievance verbally or in writing to the agency. The agency will review the complaint, investigate the matter as appropriate, and provide a response within a reasonable timeframe. Filing a grievance will not result in retaliation, reduction of services, discrimination, or any adverse action against the individual receiving services or their family. I understand that if my concern cannot be resolved through the agency's Grievance Procedure, I may contact the appropriate funding source, regulatory agency, support coordinator, case manager, or other oversight entity as applicable. By acknowledging this statement, I confirm that I have received, reviewed, and understand the agency's Grievance Procedure and have been informed of my rights regarding the filing of complaints and grievances.

Be at home at the scheduled time.

Work with the analyst for the entire session unless directed otherwise.

Complete assignments as required, make changes in the environment as needed, and follow recommendations given by the service provider.

Carry out the Behavior Plan as written.

Provide accurate information on all forms and requests for information.

Refrain from violent or threatening behavior or language.

Refrain from the use of mood-altering substances during the course of service.

Accept a referral to another provider of services when appropriate.

Notify the Company at once if illness or other emergency requires rescheduling.

I grant consent for all physicians, hospitals, schools, treatment centers, and other healthcare providers who possess pertinent medical information regarding my loved one's care to disclose personal information to the Company. I authorize the release, receipt, and exchange of medical information from my records to licensed institutions and state, federal, or accredited agencies. This release is intended to ensure continuity of care, facilitate appropriate reimbursement, substantiate the necessity of services, or comply with legal mandates as permitted by law.

I legally consent to participate in the assessment and / or treatment services provided by the Company to me or my loved one. I clearly understand the risks and benefits of participating in Behavior Analytic services under the Company. By signing / consenting to assessment and treatment, I allow the Company to implement the Behavior Support Plan (BSP) as written and presented.

As a parent or guardian of a recipient receiving ABA treatment, I consent to allow the designated Registered Behavior Technician (RBT) and / or Board Certified Assistant Behavior Analyst (BCaBA), along with his or her supervisor, to share information regarding the ABA treatment provided to my child for the purpose of supervision. I also consent to the supervisor visiting the RBT and / or BCaBA at locations where Behavior Analysis services are being provided. This supervision includes observing treatment sessions and conducting the Competency Assessment needed to maintain the RBT's and / or BCaBA's certification as a therapist. I understand that, in some cases, these supervision activities may be billable or not billable.

I authorize the [Company] to take photographs and / or video recordings of my child during the provision of services. These images and recordings may be shared with me and other authorized caregivers involved in my child's care for treatment, training, progress monitoring, and communication purposes. I understand that all media will be maintained in accordance with applicable privacy and confidentiality requirements and will not be used for marketing, advertising, social media, or any public purpose without obtaining separate written consent. I understand that I may revoke this authorization in writing at any time.

By indicating "I consent", I provide my consent to electronically sign the forms provided to me by the Company. I understand that my electronic signature is the legal equivalent of my manual signature, and I willingly consent to be legally bound by the terms and conditions outlined in this agreement. I acknowledge that no certification authority or other third-party verification is required to validate this electronic signature, and the absence of such certification or verification will not affect the enforceability of this electronic signature or any resulting contract between me and the Company. I declare that I am the caregiver and / or legal guardian, or I am authorized to enter into this agreement on behalf of the client. I agree that the terms of the agreement are equally binding whether the caregiver / legal guardian consents to the agreement or an authorized signer consents on their behalf.