Statement of Authority to Consent: I certify that I have the authority to represent the above-named client. I legally consent to assessment, release of information, and all legal issues regarding the above named client. Upon request, I will provide Play ABA with proper legal documentation to support this claim. I further hereby agree that if my status as legal guardian should change, I will immediately inform Play ABA of this change in status and will further immediately inform Play ABA of the name, address, and phone number of the person or persons who have assumed guardianship of the above-named client.
Permission for Assessment: I consent to allow the above-named client to participate in assessments including but not limited to behavioral assessment, educational assessment, and/or speech/language assessment given by a Play ABA employee to provide observations, interviews with members of the therapy team whom I give authorization to release information, interviews, observations or direct test/interview results with the above-named client.
Treatment Consent: I consent for treatment included but not limited to behavioral treatment, educational treatment, speech/language treatment to be provided for the above-named client through Play ABA, Play ABA employees, and contracted employees. I understand that the procedures used will consist of manipulating antecedents and consequences to produce improvements in behavior. At the beginning of the treatment, behavior may get worse in the environment where treatment is provided or in other settings. As part of treatment, physical prompting and manual guidance may be used. The actual treatment protocols that will be used have been explained to me by Play ABA staff. I authorize and request the implementation of the treatment procedures. I understand there is an expectation that the above-named client will benefit from this plan, but there is no guarantee that this will occur.
I understand that I may revoke this consent at anytime without penalty and I understand that there is no penalty for refusing to grant this consent. However, I cannot revoke consent for action that has already been taken. A copy of this consent shall be valid as the original. I understand that I have a right to receive a copy of this authorization upon request. I understand what this agreement means.