Parent Participation Agreement Form

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I (we), parent(s) of

 

 

 

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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.

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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.

No Show/Cancellation Policy

 

75% of scheduled appointments must be attended in order for therapy to be effective.  Any patient that fails to call and reschedule their appointment prior to the appointment time is considered a “no show.”

 

In addition to “no shows,” habitual cancellations also put your child’s therapy in jeopardy.  Three (3) consecutive cancellations or “no shows” are grounds for termination of services.

 

Any patient having three (3) “no show” appointments or three (3) consecutive cancellations will no longer reserve their appointment time and their name will be placed on our waiting list.

 

TCBT makes every effort to accommodate your schedule with appointments.  Your signature below indicates that you are aware and understand this policy.  If you have any questions please contact us.

 

Parent/Guardian Name:

 

 

 

 

 

 

 

Signature:

 

 

 

 

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ABA Provider:

 

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