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.