STATEMENT OF AUTHORITY TO CONSENT: I certify that I have the authority to legally consent to assessment, the release of information, and all legal issues involving the above- named client. Upon request, I will provide Outside the Box Behavioral Services with proper legal documentation to support this claim. I further hereby agree that if my status as legal guardian should change, I will immediately inform Outside the Box Behavioral Services of this change in status and will further immediately inform Behavioral Connections of the name, address, and phone number of the person or persons who have assumed guardianship of the above-named client.
TREATMENT CONSENT: I consent for behavioral treatment to be provided for the above- named client by Outside the Box Behavioral Services and its staff. I understand that the procedures used will consist of manipulating antecedents and consequences to produce improvements in behavior. At the beginning of treatment behavior may get worse in the environment treatment is provided (e.g., “extinction burst”) or in other settings (e.g., “behavioral contrast”). As part of the behavioral treatment, physical prompting, and manual guidance may be used. The actual treatment protocols that will be used have been explained to me. Behavior analysts are ethically obligated to provide treatments that have been scientifically supported as most effective for your child. I am aware that other interventions that I am pursuing may affect my child’s response to ABA treatment. Thus it is important to make the behavior analyst aware of those interventions and to partner with the behavior analyst to evaluate any associated therapeutic or detrimental effects of those interventions.
I understand that the specific activities, goals, and desired outcomes of these ABA services will be fully discussed with me and that I will have the opportunity to ask for clarification prior to signing this document. I also understand that I have the right to ask follow-up questions throughout the course of service delivery to ensure my full participation in services. If these services have been arranged or will be paid for by a third party (e.g., school, insurance plan, a state agency), I am aware that the third party has the following rights: determine the number of hours that are authorized, reduce the number of authorized hours, refuse certain service locations, and deny services. I also understand that my child/dependent is the primary client of the behavior analyst and that services will be designed primarily for my child’s benefit. Any other individuals or agencies (e.g., family, school professionals) who may be affected by the ABA services are considered secondary clients.
the ABA services focus on increasing my child’s skills, I understand that the first several sessions will consist of assessment activities designed to (a) evaluate his/her current skills (e.g., curricular assessments) and (b) determine which instructional strategies and interventions are likely to prove most effective (e.g., preference assessments, assessment of prompting strategies). The time allocated to these assessments will result in an improved intervention. If the services are designed to improve ongoing problem behaviors, I understand that the beginning of those services will include functional assessment and/or functional analysis activities (e.g., interviews, checklists, direct observations) that are designed to provide information critical to the development of effective treatment procedures. I may be asked to assist in gathering some of this information by recording problem behavior as it occurs. This process may take up to 4-6 weeks prior to implementing an intervention, but will increase the likelihood of effective intervention.
The subsequent services will be focused on the development of and implementation of instructional procedures and/or a behavior intervention plan. Prior to implementation, I will receive a printed copy of the results of any assessment and of any proposed instructional procedures or behavior intervention plans for my approval. The contents of those documents will be explained to me fully and any questions I have will be answered to my satisfaction. Subsequent implementation will involve training in the basics of ABA that are important for the intervention, details about the specific components of the ABA intervention, and direct practice in the components for the family, educators, and/or other service providers. Full participation in these training and activities is critical for a successful outcome. Ongoing collection of data will allow evaluation of the effectiveness of the intervention and will assist in developing any revisions that need to be made to ensure a good outcome. As Individualized Treatment Plan goals are achieved, we will discuss the discontinuation of services as we will have achieved our therapeutic objectives. In addition, at regular progress reviews we may also discuss whether continuation of services would be beneficial, and any barriers to continuation.
I understand that I may revoke this consent at any time. However, I cannot revoke consent for action that has already been taken. A copy of this consent shall be as valid as the original. I will receive a PDF copy of this document to retain for my records.