I blanks give consent for behavior analytic evaluation, assessment and treatment by Sprout, MBC and Monadnock Behavioral Consultants for my child blank I understand the risks and benefits involved as well as the potential negative side effects of behavior change. I understand that the failure to comply with or the disruption of treatment could result in mild to significant regression. Treatment has been explained to me and I have had the opportunity to seek clarification and ask questions. I acknowledge that a behavioral health provider is approved to perform only the work in which they are trained, certified and knowledgeable. No promises or guarantees have been made to me about my treatment or its potential outcomes. If I am reviewing this consent form for an individual that is under 18 of whom I am the parent/guardian, I acknowledge the importance of accurate reporting on their behalf of their needs and progress. Regardless of whether services are for myself or for someone I legally care for, I agree to play a continued, vital and active role in treatment. I acknowledge the importance of open and clear communication with the clinician/s delivering service. I retain the right to terminate treatment at any time.