Child Consent Form

TWO WAY CONSENT FORM

REALISING CONFIDENTIAL INFORMATION ABOUT ABA THERAPY
Parental Information
Name of Father

First NameLast Name
Phone Number of Father
Format: (000) 000-0000.
Email Address of Father
example@example.com
Address of Father

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Mother

First NameLast Name
Phone Number of Mother
Format: (000) 000-0000.
Email Address of Mother
example@example.com
Address of Mother

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Child

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Between

Consenting Parties
Name of Person/Organization
Address of Person or Organization
Name of BCBA
And
Name of Person/Organization
Address of Person or Organization
Name of BCBA
Effectivity Period
Date Start

MonthDayYear
Date
Date End

MonthDayYear
Date
I/We, {nameOf4} and/or {nameOf23}, hereby declare that I am/We are the parent(s)/legal guardian of {nameOf}, who was born on the {dateOf}.

I/We hereby authorize {nameOf29} of {addressOf} to release and share information about my child's ABA Therapy with {nameOf44} of {addressOf45}.

This authorization shall be effective from {dateStart} until {dateEnd}.
Signature of Father

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Signature of Mother

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Date signed

MonthDayYear
Date
Date signed

MonthDayYear
Date
Should be Empty:

TWO WAY CONSENT FORM