Consent for Treatment

Consent for Treatment

 

I hereby authorize the participation of my child, and myself for treatment involving behavioral techniques for children and families, provided by Tri-Cities Behavioral Therapy. Included in this authorization are the following:

 

My child has not been diagnosed with any major medical conditions such as blindness, significant hearing loss, uncontrolled seizures, or severe delays in motor development. My child does not present with physical restrictions which would endanger him or her in the event that behavior modification techniques requiring physical exertion are used. 

 

I understand that the purpose of this treatment is to teach me and other care providers how to implement behavior modification techniques.  These techniques will be described, demonstrated, and practiced during treatment and teaching sessions.  I understand these techniques may include, but are not limited to, reinforcement, extinction and punishment.

 

I understand that for the maximum benefit to my child, my participation during treatment is essential.  I understand that I am expected to attend training sessions, practice the procedures, and receive feedback on my techniques from the consultant.

 

I understand that only family members and people who work directly with my child can attend training sessions.  I agree to obtain the consultant’s consent for other professionals to attend the training sessions.

 

I understand that Mary Smith (Director, TCBT) or the consultants working for TCBT are not liable for the progress of my child. It has been explained to me that some children progress well while others may not, though every effort will be made to individualize a behavior plan that is effective for my child. 

 

I understand that training sessions will teach me to implement basic behavioral treatments with my child only.  I understand that training is an on-going process and that the acquisition and maintenance of my skills will be assured through participation in follow-up training sessions.

 

I understand the limits of my training and agree not to apply my skills beyond the educational program of my child. I understand that all programs and written materials provided to my child are copyrighted material.  I agree not to sell or otherwise distribute these materials without the written consent of Mary Smith.  I understand that distribution of written materials can lead to termination of services and this agreement.

 

I agree to release my child’s medical, psychological and developmental assessment records to Mary Smith or the consultants working for TCBT upon request.  All records and reports will be kept on file in a confidential manner. I understand that no information that identifies my child or my family will be released without my written consent and that all identifiable information will be protected within the limits of the Federal Law of the United States of America.

 

I understand that I have the right to terminate my relationship with Mary Smith or the consultants working for TCBT at any time for any reason.  If such termination should occur, fees for treatment will be pro-rated.