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Parent Participation Agreement Form

Parent Participation Agreement

I ( we) parent(s) of

understand that my (our) participation in Tri-Cities Behavioral Health's ABA program as outlined by the ABA Service Provider is vital for successful outcomes of treatment. I (we) understand that failure to be active in any suggested recommendations/or guidelines given during parent training/family training can result in termination of services.

If my (our) child is terminated from services as a result of my (our) lack of involvement with the program and I (we) later wish for my (our) child to resume therapy with TCBT, I (we) will need to contact the pediatrician/family doctor of my (our) child and have a new referral sent to TCBT. At that time, my (our) child will be placed back on a waiting list.

If you would rather print this form and return to us in person or by mail, click on the button below labeled "Printable Forms".

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Our address is. Tri-Cities Behavioral Therapy 321 West Walnut Street Box #2 Johnson City, Tennessee 37604

Click (Submit) to finish the form. If you can not continue make sure all required fields with an ( * ) have been filled out. Any missed fields will be highlighted in red to make it easier in finding them.

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