Client and Caregiver Forms

I, the undersigned, voluntarily give my informed consent for Autism Unchained LLC to provide Applied Behavior Analysis (ABA) services through telehealth. I understand that telehealth services may include direct therapy, caregiver training, clinical supervision, treatment planning, and consultation delivered through secure video conferencing technology. I understand that telehealth may be used when in person services are not available, when it supports consistency of services, or when it is clinically appropriate to meet my child’s needs across home and community routines.

I understand that telehealth involves communication through electronic methods, and I agree to participate using a device with video and audio capabilities such as a phone, tablet, or computer. I understand that telehealth services depend on reliable internet connectivity and may be impacted by technical difficulties such as poor connection, audio delays, video disruption, or the session ending unexpectedly. I understand that Autism Unchained LLC will make reasonable efforts to troubleshoot and continue services when possible, and that sessions may be rescheduled if the technology prevents effective service delivery.

I understand that telehealth services may require active caregiver participation to support my child’s learning, safety, and engagement. I understand that the clinician may coach me to implement procedures such as prompting, reinforcement, environmental arrangement, and behavior intervention strategies. I understand that I may be asked to practice skills during the session, collect simple data, and support transitions or behavior management as needed. I understand that caregiver involvement is often an essential component of telehealth because the clinician is not physically present to manage materials, ensure safety, or implement hands on intervention procedures.

I understand that telehealth ABA services may include observation of my child in their natural environment and may involve discussions about behavior, learning, development, family routines, strengths, and areas of need. I understand that the clinician may provide feedback, recommendations, and treatment updates based on observed behavior and collected data. I understand that my child’s treatment will remain individualized and that goals, procedures, and service delivery decisions will be based on clinical judgment, medical necessity, and ongoing progress monitoring.

I understand the benefits of telehealth may include increased access to services, reduced travel demands, improved consistency of caregiver training, and the ability to support skills within real life routines. I understand that telehealth may also have limitations, including reduced ability to physically prompt, manage unsafe behavior directly, or control the environment in the same way as in person sessions. I understand that if telehealth is no longer clinically appropriate or effective, Autism Unchained LLC may recommend a change in service delivery, including transitioning to in person services when available or referring to additional supports.

I understand that confidentiality is important in behavioral health services, and I agree to participate in telehealth sessions in a private and distraction reduced area whenever possible. I agree to make reasonable efforts to prevent others from overhearing clinical discussions unless I provide permission for them to be present. I understand that Autism Unchained LLC will use reasonable safeguards to protect my family’s confidentiality, but I acknowledge that all electronic communication carries some level of risk. I understand that I am responsible for the privacy of my own environment, including the location I choose for sessions and the security of my personal device and internet connection.

I understand that telehealth sessions are not intended for emergency services. I understand that if my child is experiencing a medical emergency or immediate safety concern, I should call 911 or go to the nearest emergency room. I understand that if there is an urgent behavioral crisis, I may contact local crisis resources or emergency services as appropriate. I understand that the clinician may pause or end a telehealth session if a situation becomes unsafe, if the environment is not appropriate for services, or if immediate in person support is needed.

I understand that I may withdraw my consent for telehealth services at any time by providing written or verbal notice to Autism Unchained LLC. I understand that withdrawing consent may affect service availability and continuity, and I understand that the clinical team will collaborate with me to explore alternative service delivery options when possible. I understand that agreeing to telehealth is voluntary and that I have the right to ask questions at any time regarding the telehealth process, treatment procedures, or my rights as a participant in services.

I confirm that I have had the opportunity to review this Telehealth Consent Form, ask questions, and receive answers that I understand. I agree to participate in telehealth ABA services through Autism Unchained LLC under the conditions described above.

Autism Unchained is committed to providing ethical, culturally responsive, and clinically appropriate Applied Behavior Analysis (ABA) services that promote dignity, safety, and meaningful progress. This document outlines the rights and responsibilities of clients and caregivers participating in services. These expectations support collaboration, consistent treatment implementation, and a respectful therapeutic relationship.

Client Rights
Clients and caregivers have the right to be treated with respect, dignity, and fairness at all times. Autism Unchained provides services without discrimination and honors each family’s culture, values, and lived experiences. Clients have the right to receive services that are individualized, clinically appropriate, and based on data and professional standards. Caregivers have the right to ask questions, receive clear explanations of treatment procedures, and participate in decision making related to goals and intervention strategies. Clients also have the right to request information about staff credentials and roles involved in service delivery, including the supervising BCBA and team members assigned to the case.

Clients and caregivers have the right to privacy and confidentiality. Autism Unchained protects protected health information (PHI) and follows HIPAA guidelines and applicable confidentiality laws. Caregivers have the right to review their child’s clinical records, request corrections to information when appropriate, and receive information about how records are used and maintained. Clients and caregivers have the right to decide who Autism Unchained may communicate with outside the clinical team through signed Release of Information documentation. Caregivers also have the right to file a complaint or voice concerns regarding services without fear of retaliation.

Clients have the right to receive safe services in an environment that supports learning and well being. Autism Unchained prioritizes least restrictive practices and seeks to incorporate assent and participation whenever clinically appropriate. Caregivers have the right to request modifications to treatment based on safety concerns, medical changes, or family circumstances, and they have the right to discontinue services if they choose. Clients also have the right to receive information regarding appointment scheduling, attendance expectations, and the financial policies connected to service delivery.

Client and Caregiver Responsibilities
Clients and caregivers are responsible for providing accurate and current information that supports safe and effective services. This includes communicating updates regarding medical conditions, medications, allergies, safety risks, school placement, or significant life changes that may affect the client’s behavior or treatment progress. Caregivers are responsible for maintaining a safe environment for services and for notifying Autism Unchained of concerns that may impact the ability to provide sessions, including active safety risks or environmental barriers.

Caregivers are responsible for supporting consistent attendance, arriving on time when applicable, and communicating cancellations or schedule changes as early as possible. ABA is most effective when services occur consistently and treatment procedures are implemented as designed. Repeated late cancellations, no-shows, and interruptions in service may impact progress and may affect the ability to maintain scheduled service hours. Caregivers are responsible for participating in caregiver training when recommended, as this supports generalization and maintenance of skills across settings and routines.

Caregivers are responsible for maintaining respectful communication with all Autism Unchained team members. This includes engaging in collaboration, asking questions when clarification is needed, and addressing concerns through appropriate channels. Autism Unchained team members are responsible for providing professional services, and caregivers are responsible for supporting a therapeutic environment that allows the clinical team to work effectively and safely. Autism Unchained also expects caregivers to follow financial policies and to provide updated insurance information when changes occur, including plan changes, coverage termination, or address updates that could affect billing or authorization.

Caregiver training is a core part of Applied Behavior Analysis (ABA) services because it supports skill generalization, maintenance, and meaningful progress across daily routines and natural environments. Autism Unchained values caregivers as essential partners in the treatment process and recognizes that caregiver participation strengthens outcomes by increasing consistency, improving follow through with intervention strategies, and supporting long term behavior change. This form outlines the purpose of caregiver training and confirms your consent and commitment to participate to the best of your ability.

Caregiver training may include direct instruction, modeling, role play, feedback, and guided practice while using evidence based behavior analytic strategies. Training may focus on teaching caregivers how to implement prevention strategies, increase functional communication, strengthen adaptive skills, and respond effectively to challenging behavior using individualized intervention plans. Caregiver training may include topics such as reinforcement, prompting strategies, shaping, extinction procedures when clinically appropriate, functional communication training, visual supports, daily routine structure, and data collection methods when needed. Training goals will be individualized and will be based on the child’s treatment plan, caregiver priorities, and the skills needed to support success in the home and community.

I understand that caregiver training is designed to improve my ability to support my child’s progress outside of direct therapy sessions. I understand that my participation may include attending scheduled caregiver training meetings, practicing strategies between sessions, and collaborating with the clinical team to adjust routines and supports as needed. I understand that treatment recommendations are based on data and clinical judgment and may be updated over time. I also understand that progress can vary and that behavior change may require consistency, repetition, and patience. I understand that participation is expected to be respectful and collaborative, and that I may ask questions or request clarification at any time during training.

I acknowledge that caregiver training is not intended to replace mental health counseling, parenting therapy, or crisis intervention services. I understand that Autism Unchained provides behavior analytic treatment and caregiver coaching related to my child’s goals and behavior support needs. I understand that Autism Unchained will prioritize safety, dignity, and least restrictive practices and will work with me to select strategies that are feasible and appropriate within my home routines. I understand that my participation and follow through will impact the effectiveness of treatment and the rate of skill generalization.

1. Therapy Space and Supervision
The therapy area is clear enough for movement and learning activities.
There is adequate lighting and ventilation in the session area.
Pets will be secured or separated during sessions if needed for safety.
An adult caregiver (18+) will be present in the home during sessions unless otherwise approved in writing.
Any visitors in the home during sessions will be communicated in advance when possible.

2. Emergency Access and Safety Planning
The caregiver can be reached during the full session time.
Emergency exits are accessible and not blocked.
The home address is confirmed and accurate for emergency response needs.
The caregiver will notify the clinical team of any safety concerns immediately.

3. Medical and Allergy Information
The caregiver has communicated any allergies, medical needs, or seizure history.
EpiPen or emergency medication is available if required for the client.
The caregiver will notify Autism Unchained of any medication changes or health updates that may affect behavior or participation.

4. Environmental Hazards
Medications, vitamins, and supplements are stored out of reach or locked.
Cleaning supplies and chemicals are stored out of reach or locked.
Sharp objects (knives, scissors, tools) are stored out of reach or locked.
Small items that may be choking hazards are kept out of reach when needed.
Cords, outlets, and unsafe household items are managed to reduce risk.

5. Elopement and Safety Risks (if applicable)
Doors are secured as appropriate for the client’s safety needs.
The caregiver will inform the team if the client has a history of elopement.
The caregiver will collaborate on a safety plan if wandering or elopement occurs.

6. Water Safety (if applicable)
The caregiver has informed the team if there is accessible water (pool, pond, bathtub, open water).
Pools or water hazards are secured as appropriate (gates, locks, supervision plans).

7. Firearms and Weapons Safety
If firearms are present in the home, they are unloaded, secured, and stored in a locked safe.
Ammunition is stored separately and locked.
Weapons or other dangerous items are inaccessible during sessions.

8. Smoking, Vaping, and Substances
The home therapy area will be smoke-free during sessions.
Alcohol, marijuana, or other substances will not be used in the session area during services.
Any substance-related safety concerns will be communicated immediately.

9. Technology and Recording
The caregiver understands that recording sessions (video/audio) requires prior written consent from Autism Unchained.
The caregiver will inform the team if home cameras are present in the therapy space.

10. Pests/Insects and Environmental Conditions
The caregiver will notify Autism Unchained if there are active pest concerns in the home (e.g., roaches, bed bugs, fleas, ants, spiders, rodents) that could impact health, safety, or the ability to provide services. If pests are present in the therapy area or create unsafe conditions, Autism Unchained may pause or reschedule sessions until the environment is safe and appropriate for service delivery.

11. Behavior Safety Considerations
The caregiver has communicated any history of aggression, self-injury, or property destruction.
The caregiver will collaborate with the team on safety procedures if high-risk behaviors occur.
The caregiver understands the clinical team may recommend changes to session structure to maintain safety.

Caregiver Acknowledgement
I confirm that the information provided is accurate to the best of my knowledge. I understand that maintaining a safe home environment supports effective treatment and protects the client, caregivers, and clinical team.