Client Consent Form

5979 NW 151 Street, Suite 102-i . (786) 431-5801 .

info@jumpstartdevelopementalservices.com

www.JumpstartDevelopmentalServices.con
Name of Client *
Informed Consent for Treatment

The undersigned acknowledges that Jumpstart Developmental Services LLC, hereinafter referred to as

JUMPSTART DEVELOPMENTAL SERVICES, 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 parties for the above-named patient/client. The specific terms of this Informed

Consent for Treatment are as follows:

JUMPSTART DEVELOPMENTAL SERVICES 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.

JUMPSTART DEVELOPMENTAL SERVICES 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. JUMPSTART

DEVELOPMENTAL SERVICES 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

The undersigned hereby acknowledges the potential risks of injury based on the strategies

implemented by JUMPSTART DEVELOPMENTAL SERVICES 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 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

JUMPSTART DEVELOPMENTAL SERVICES. The undersigned acknowledges and agrees that if the status

of legal guardian should change, they will immediately notify Jumpstart Developmental Services, of the name, address, and telephone number of the person who has assumed guardianship of the below-

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 Jumpstart Developmental Services, with proper legal documentation to support this claim.

Informed Consent for Treatment Continued

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 JUMPSTART DEVELOPMENTAL SERVICES 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 JUMPSTART DEVELOPMENTAL SERVICES 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.
Signature of Client* (required if over 18 years of age)

Clear
Date

Month Day Year
Date
(required if over 18 years of age)
Name of Client *
Signature of Caregiver/Guardian *

Clear
Caregiver Name *

First Name Last Name
Date *

Month Day Year
Date
Client Name *
Date of Birth *

Month Day Year
Date

Behavioral Analysis Services Expectations

Behavioral Analyst Description: A Behavioral Analyst provides community-based therapy support services. The Behavioral Analyst provides an assessment for the consumer along with the development of a plan of care and insures the implementation of the plan.

Behavior Analyst Responsibilities:
- If requested and approved a Functional Behavioral Assessment (FBA) will be completed within 30 days of receipt of the Personal Service Authorization (PSA
- Development of a Behavior Analysis Service Plan (BASP) that is incorporated into the Individual Service Plan (ISP) will be due within 90 days from receipt of the PSA.
- Provides services only within the margins of the PSA. Submit applicable plans to the Local Review Committee, completes revisions and submits updates as necessary and required. Implements the BASP as well as train and monitor caregivers.
- Collects and analyzes data received from caregivers.
- Complete Case Note / Client Contact Log with signed confirmation of services.
- Complete Quarterly Service Summaries and Annual Reports in relation to the Support Plan effective date, to include Monthly Graphs, meeting when requested.
- Regular correspondence with the consumer's Support Coordinator and relevant caregivers Coordinate appointments for service delivery.
- Provide on-sight services in the home, community, or school.
- Active member of the consumer's treatment team.
- Attendance at the consumer's ISP
By signing below, I am indicating that I fully understand the role my Behavior Analyst has in providing me with exceptional services. I have also had the responsibilities of the Behavior Analyst explained to me.
Signature of Caregiver: *

Clear
Date *

Month Day Year
Date
Name of Client *

Behavior Analysis Services Expectations

Behavioral Assistant or Registered Behavior Technician Description:

A Registered Behavior Technician provides community-based therapy support services. The Registered Behavior Technician works with a Behavior Analyst to implement the behavior plan, collect data, and train caregivers.

Behavior Assistant/ Registered Behavior Technician Responsibilities:
- Provides services only within the margins of the Personal Service Authorization (PSA Implements the Behavior Analysis Service Plan (BASP) as well as train and monitor caregivers.
- Complete Case Note / Client Contact Log with signed confirmation of services Complete Quarterly Service Summaries and Annual Reports in relation to the Support Plan effective date, to include Monthly Graphs.
- Submit all Summaries and Reports to office each month by all required deadlines. Active member of the consumer's treatment team.
- Attendance at the consumer's ISP meeting when requested.
- Regular correspondence with the consumer's Support Coordinator and relevant caregivers Coordinate appointments for service delivery.
- Provide on-sight services in the home, community, workplace or ADT
By signing below, I am indicating that I fully understand the role my Behavior Assistant has in providing me with exceptional services. I have also had the responsibilities of the Behavior Assistant explained to
Signature of Caregiver

Clear
Date *

Month Day Year
Date
Name of Client *

Client Bill of Rights

I have the right to dignity, privacy, and humane care, including the right to be free from sexual abuse in my residence. I have the right to practice my faith. I have the right to receive services which protect my personal liberty, and those services will be provided in the least restrictive conditions necessary to achieve the purpose of treatment. I have the right to participate in a program to promote my educational and/or training goals without prejudice of age or disability. I have to the right to sex education, marriage, and family planning when applicable. I have the right to social interaction and

participation in community activities. I have the right to physical exercise and recreational activities.I

have the right to be free from harm, including unnecessary physical, chemical, or mechanical restraint, isolation, excessive medication, abuse or neglect. I have the right to consent to or refuse treatment, subject to the provisions of S. 393.12(2a) or chapter 744. I have the right to receive benefits or participate in activities which receive public funds. I have the right to vote. I have the right to unrestricted communication; mail, telephones, visitation, personal possessions (clothing, personal effects), monies (in accordance to s.407.12. Included in my right to have personal possessions will be the access to individual storage space for my private use. I have the right to appropriate medical and dental care. I have the right to humane discipline. NO treatment plan or behavior plan will be used which contain the use of noxious of painful stimuli. My records will remain confidential.

A copy of this Bill of Rights was explained and provided to me.
Signature of Client

Clear
Date

Month Day Year
Date
(required if over 18 years of age)
Signature of Caregiver/Guardian *

Clear
Date *

Month Day Year
Date

Name of Client *
Abuse/Neglect Policy

All Jumpstart Developmental Services Personnel are legally and ethically bound to report situation of suspected abuse and/or neglect. Our policy is to report suspected abuse/neglect immediately to the appropriate authorities. The administrator will immediately report such knowledge or suspicion to the central abuse registry and tracking system of the Department of statewide toll-free telephone number.

1-800-ABUSE or TTY users call 1-800-453-5145 condense I understand this policy and by signing acknowledge my agreement with the stipulations in this policy.
Signature of Client

Clear
Date

Month Day Year
Date
(required if over 18 years of age)
Signature of Caregiver/Guardian *

Clear
Date *

Month Day Year
Date

Name of Client *
First Aid Release Form

I agree to allow personnel of Jumpstart Developmental Services to administer simple first aide in the form of cleaning and bandaging a cut, burn, or scrape. I understand that Jumpstart Developmental Services personnel are not authorized to administer medications and medical attention beyond simple bandaging. Any injury that occurs will be referred out to the nearest hospital and/or critical care facility or by dialing 911. Jumpstart Developmental Services personnel are not authorized to transport injured recipients.

I agree to the terms as stipulated.
Signature of Client

Clear
Date

Month Day Year
Date
(required if over 18 years of age)
Signature of Caregiver/Guardian *

Clear
Date *

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

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