The approach to behavioral intervention will utilize Applied Behavior Analysis (ABA) principles. ABA is the use of behavioral methods to measure behavior, teach functional skills, and evaluate progress. A unique plan will be created that results in long-lasting positive outcomes and an enhanced quality of life. Behavioral treatments are clinical processes that involve a professional arrangement, and may include diagnostic testing, speech and language evaluation and treatment, and/or occupational therapy evaluation and treatment. Therapy is regulated by laws, ethics, your rights as a client, and by standard business practices. Before intervention can begin, your agreement to the business practices described herein is required.

Treatment Termination

If at any time during the course of your treatment it is determined services cannot continue, a Transition to Termination notice can be provided to you explaining the justification for this decision. Ideally, services end when treatment plan goals have been achieved. Additional conditions of termination can include:

• You have the right to stop treatment at any time. If you make this choice, referrals to other therapists may be provided (if available).
• Professional ethics mandate that treatment continues only if it is reasonably clear you are receiving benefit. If it is determined that the services are not proving to be clinically beneficial, ethical conduct requires a termination of treatment.
• Other legal or ethical circumstances may arise and lead to termination of treatment, such as the clinical expertise of the Consultant being inappropriate or insufficient for the client/individual receiving treatment. Please note: the Consultant will not diagnose, treat, or advise on problems outside the recognized boundaries of his/her competencies.
• Other situations that warrant termination may include: drug abuse, disclosing illegal intentions or actions, inappropriate behavior during services, or failure meet parent participation expectations.

Possible Risks Associated with Treatment

Like many things in life, therapy/behavioral treatment has inherent risks. Some of these risks are:

• Disruptions in your daily life that can occur because of therapeutic changes
• No promises can be made regarding learner progress. Some individuals progress and learn skills quickly, while other learners take longer to learn skills or experience difficulty retaining skills once learned
• Emotional pain due to exploring personal issues and family history
• Emotional pain due to tolerating your child’s reaction to behavioral intervention
• Initial increases in the duration, frequency, or intensity of problem behaviors due to the “Extinction Burst”
• Although treatment begins with the hope of behavioral improvement and positive outcomes in the overall family functioning, there is no guarantee that this will occur. There is, however, a better chance of improvement occurring if all caregivers in the household participate in the therapy.
• Across studies, a small percentage of individuals receiving ABA treatment show relatively little improvement. More research is needed to determine why some individuals respond more favorably than others. Currently it remains difficult to predict the extent to which an individual will benefit from ABA treatment.

Possible Benefits Associated with Treatment

Multiple studies across decades of time have contributed to the current understanding of the benefits of Applied Behavior Analysis:

• Improvements in communication, social relationships, play, self-care, school, and employment
• Increased participation in family and community activities
• Improvements in “school readiness”
• Significant improvements (socially valid improvements) in learning, reasoning, and adaptability to change
• Studies have demonstrated that there is no age or diagnosis for which ABA services have no potential benefit, however it is well established that ABA treatment is most impactful for young children (1-4), and when delivered intensively (25-40 hours a week). Individuals who receive intensive ABA treatment make larger improvements in more skill areas than do individuals who participate in other (non ABA) interventions.

HIPAA

I hereby give my consent for the Applied Behavior Center for Autism to use and disclose protected health information (PHI) about my child to carry out treatment, payment and health care operations (TPO). If I do not sign this consent, or later revoke it, Applied Behavior Center for Autism may decline to provide treatment to my child.

I understand and recognize my right to request inspection, review, and/or obtain copies of any medical records relating to services provided to my child that are collected, maintained, or used by the Applied Behavior Center for Autism. Any such request must be made in writing to the CEO, who shall review and respond to the request without any unnecessary delays. Records are released within 5-10 business days. Fees for records apply for outside agencies, attorneys, or other parties at $0.25/page due within 30 days from date of statement. Please refer to the Notice of Privacy Practices, available by written request, for further explanation.

Financial Responsibility

I assume personal responsibility for the payment of all fees, deductibles, co-pays/co-insurance and agree to the rules and regulations of the Applied Behavior Center for Autism. Payment for services will be due prior to diagnostic testing or evaluations or within 30 days of the statement date if billed to insurance.

My signature below verifies that I have read all of the information contained in this Informed Consent and that I asked questions about anything I have not understood up to this point.

By signing, I freely acknowledge my willingness to undergo treatment using Behavioral Therapy methods:

I acknowledge that Therapy involves potential physical, emotional, and mental risks, including but not limited to the potential for property damage, personal injury, and emotional duress. I acknowledge that proper implementation of Applied Behavior Analysis requires ongoing training and support from a Certified Behavior Analyst, adherence to the treatment plan, and diligence in data collection.