INFORMED CONSENT AND WAIVER

Client: ______DOB: ______

STATEMENT OF AUTHORITY TO CONSENT: I certify that I have the legal authority to consent to treatment, release of information, and all legal issues involving the above-named client. Upon request, I will provide Behavioral Developmental Services, LLC. with proper legal documentation to support this claim. I further agree that if my status as legal guardian should change, I will immediately notify Behavioral Developmental Services, LLC of the name, address, and telephone number of the person who has assumed guardianship of the above-named client

The undersigned acknowledges that Behavioral Developmental Services, LLC. hereinafter referred to as BDS, is providing services to, or for the benefit of the above named client and is requiring, as partial consideration for providing said services, the execution of this Consent and Waiver which is being executed by the undersigned as the natural parent, guardian, or other responsible party for the aforementioned patient/client. The specific terms of this Consent and Waiver are as follows:

  1. BDS is providing services including, but not necessarily limited to behavior analysis services, evaluation, program development, and treatment of the aforementioned patient/client.
  2. BDS will provide the aforementioned services in a professional manner and will take every precaution within reason to insure the safety of the client. BDS has informed the undersigned that treatment strategies are often play-based or interactive in nature and accordingly, can potentially pose risk of inadvertent injury to the client.
  3. The undersigned herby acknowledges the potential risk of inadvertent injury to the client.
  4. The undersigned hereby acknowledges that a copy of the BDS Intervention Policies for Parents & Therapist has been provided to me, and I have read through it and understand that there are times when a client may need to be restrained in order to prevent injury to self, others, elopement, or destruction of property.
  5. The undersigned hereby acknowledges the potential risks of injury based on the strategies implemented by BDS and consents to the same despite the disclosed risks. Furthermore, the undersigned herby 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 patient/client as a result of the provision of services.
  6. The undersigned, on behalf of the undersigned as well as the client, the heirs, devisees, or assignees, hereby agrees to hold harmless and indemnify BDS from any and all losses which BDS may experience or be exposed to by reason of injury to the client for provision of the services as outlined herein. The indemnification shall include any all losses as well as attorney’s fees and costs.
  7. The undersigned acknowledges and agrees that the executions of this form, and the promises and conditions as set forth herein, are partial consideration for the provision of services to the client by BDS.
  8. The undersigned acknowledges and agrees that the undersigned fully understands the terms of this Agreement and has had an opportunity to consult with independent counsel prior to

Treatment Procedures and Consent

A Behavioral Support Plan will be constructed which specifies the behavioral intervention recommended at this time. By signing this form, you consent to such treatment and the procedures designated on the attached plan. Behavioral services will involve training, consultation, program monitoring and the application of behavioral principals to effectively treat the problem behavior at this time. While results cannot be guaranteed, such procedures have been demonstrated in behavior analysis research to change problem behaviors; the proposed treatment is a scientific evidenced-based recommendation. Signing this document indicates that you have been apprised of such issues and provide initial consent to the proposed behavioral treatment.

I have had the procedures being proposed for the behavioral intervention explained to me verbally and/or in writing

I understand that I may request that the intervention/treatment be stopped at any time.

I understand that I can request to view how any of the behavioral procedures would be implemented prior to their implementation through discussion and/or role play demonstration.

I understand that behavior Analysis is a service that involves both direct and indirect services.

I have been explained the potential advantages of implementing the behavioral treatment, as well as the disadvantages of not proceeding with the proposed behavioral treatment

I have been told that the person conducting the training has the appropriate license or certification. Such training/licensure/certification allows him or her to provide such a training service

I understand that at times due to the severe behavior of a client being treated that a BDS employee trained according to the principals of Quality Behavior Services (QBS) may need to restrain my child to prevent injury to self, others, elopement, or destruction of property.

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Signature of Parent/Guardian DATE

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Signature of Client DATE

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Signature of Behavior Analyst DATE