The undersigned acknowledges that Full Spectrum Behavior Analysis, LLC, hereinafter referred to as FSBA, is providing services to, or for the benefit of the below named client and is requiring, as partial consideration for providing said services, the execution of this Informed Consent for Treatment which is being executed by the undersigned as the natural parent, guardian, or other responsible party for the below named patient/client. The specific terms of this Informed Consent for Treatment are as follows:
- FSBA is providing services including, but not necessarily limited to behavior analysis services, behavior assistant services, evaluation, program development, and treatment of the below named client.
- FSBA will provide the aforementioned services in a professional manner and will take every precaution within reason to ensure the safety of the client.
- The undersigned herby acknowledges the potential risk of inadvertent injury to the client. FSBA has informed the undersigned that treatment strategies are often play-based or interactive in nature and accordingly, can potentially pose risk of unintended injury to the client.
- The undersigned hereby acknowledges the potential risks of injury based on the strategies implemented by FSBA and consents to the same despite the disclosed risks. Furthermore, the undersigned hereby waives, on behalf of the undersigned as well as the patient, together with the heirs, devisees, or assignees of the undersigned or the patient, any and all liability for personal injury, physical, or otherwise, which may be incurred by the client as a result of the provision of services.
- The undersigned acknowledges and agrees that the execution of this form, and the promises and conditions as set forth herein, is partial consideration for the provision of services to the client by FSBA.
- The undersigned acknowledges and agrees that if the status of legal guardian should change, they will immediately notify Full Spectrum Behavior Analysis, LLC, of the name, address, and telephone number of the person who has assumed guardianship of the below-named client
- The undersigned acknowledges and agrees that they have legal authority to consent to treatment, release of information, and all legal issues involving the below-named client. Upon request, I will provide Full Spectrum Behavior Analysis, LLC, with proper legal documentation to support this claim.
- The undersigned agrees to all interventions and described in the client’s behavior analysis service plan. I have had the opportunity to ask questions and receive further clarification on procedures as needed. If I wish to terminate behavioral services with my current provider at any time, I will notify the behavior analyst and consent to the behavior analysis service plan will be withdrawn immediately. I also acknowledge that my Behavior Analysis service providers may terminate services if I am not implementing the strategies I consented to in this behavior plan.
By signing below, I verify that I have read and understand the above Informed Consent for Treatment, agree to adhere to it, and wish to have FSBA provide services and that the provision of services will be contingent upon adherence to this agreement and full participation by the caregiver/guardian. If at any time there is not full participation and cooperation by the caregiver/guardian, I understand FSBA may terminate services following notice of 30 days. I also understand that I may discontinue services at any time and will be held accountable to pay for services rendered up to that point.