POC Attestation Behavior Support Plan

Client Name*

Date of Assessment*

Estimated Date

Parent/Guardian Name*

BCBA Name*

Service Location*

I attest that I have been provided with the North Georgia Autism Center’s plan of care for my child. We have completed the assessment process and we are committed to attaining services with the North Georgia Autism Center.

As the parent/guardian of: Client Name*

Client Name

The BCBA has reviewed the goals with me and I agree with the treatment plan*

Guardian Initials

I have reviewed and I understand the included behavior support plan*

Guardian Initials

I have been informed about the necessary parent involvement protocols and I am committed to my child's success and I will attend a minimum of one monthly training session at a time that is mutually agreed upon*

Guardian Initials

The North Georgia Autism Center has answered our questions and we are ready to begin services once authorized by insurance.

ParentGuardian Signature*

Parent/Guardian Name

First NameLast Name

Interview-Informed Synthesized Contingency Analysis (IISCA) Consent Form

Dear Parent/Guardian,

As as way to best serve your child,

Client's Name:*

First and Last Name

, we would like to conduct As a way to best serve your child, an interview-informed synthesized contingency analysis (IISCA A functional analysis is the process of:

Identifying behavior(s) that negatively impact school performance, daily living, etc.
Identifying environmental events that impact these behavior(s)
Determining the cause/function of the behaviors(s)
Outlining the necessary changes needed to be made by the clinic/school, teacher/therapist, student and parent/guardian in order to allow the child to learn successfully.

An IISCA may include, but it not limited to, the following components:

Interviews completed by the student (if applicable), therapist(s), and parent(s)/guardian(s) regarding the child's behavior.
Information gathering tools (e.g. file review, assessment scales, ABC data, etc
Direct observations of child's behavior under various conditions (environment is manipulated systematically to see impact on behavior)
Data collection on child's behavior Interventions to address child's behavior, which focus on decreasing negative behavior and teaching new, appropriate replacement behaviors
Ongoing data collection to evaluate intervention effectiveness
Safety or crisis plan, if necessary We greatly appreciate your involvement in this plan during each step in this process.

If you have any questions regarding this process, please contact us at 470-473-5920, or please reach directly out to the BCBA.

Please sign below to indicate whether or not you give consent to conduct a functional behavior assessment (FBA).

Contact

Contact #:

Type a question*

I give consent for my child to participate in a functional behavior assessmentI do NOT give consent for my child, functional behavior assessment.

ParentGuardian Signature*

Parent/Guardian Name

First NameLast Name