FUNCTIONAL BEHAVIOR ASSESSMENT (FBA) CONSENT

FUNCTIONAL BEHAVIOR ASSESSMENT (FBA) CONSENT

Acclaim Autism, 2929 Arch St, Suite 1700 Philadelphia PA 19104
As a way to best serve your child, Acclaim Autism would like to conduct a Functional Behavior Assessment (FBA). A Functional Behavior Assessment is the process of collecting information to help identify your child’s behaviors that interfere with learning and to determine why these behaviors occur.
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An FBA may include, but is not limited to:
- Direct interaction with your child.
- Interviews completed with other providers(s), parent(s)/guardian(s), and the child (if applicable) regarding the child’s behavior.
- Information‐gathering tools (e.g., cumulative file review, behavior rating scales, teacher rating scales, self‐assessment).
- Direct Observations of child’s behavior.
- Data collection on child’s behavior.
The purpose of the FBA is to collect information to help develop a Behavior Intervention Plan (BIP) for your child to improve his/her performance and success. A BIP may include, but is not limited to:
- Interventions to prevent and reduce problematic behaviors.
- Teaching new, appropriate replacement behaviors.
- Ongoing data collection to evaluate the effectiveness of the plan.
- Safety or crisis plan, if necessary.
We greatly appreciate your involvement in this process.

The FBA will be completed and shared with you within 30 days of services commencing. If you have any questions regarding this process, please contact the Clinical Director at 888-805-8206.
Please indicate if you consent to a Functional Behavior Assessment (FBA) on your child:*

I give consent to conduct a Functional Behavior Assessment on my child.I do not give consent to conduct a Functional Behavior Assessment on my child.
Authorization*

I have read and understand this form. If this form is being signed digitally, I further understand I may submit this request through a paper form by mail or fax if I do not wish to use the digital version.
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Parent / Guardian Signature*

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This form is HIPAA-compliant.
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