ABA Behavioral Therapy Application

Client Information

Mother or Legal Guardian 

Father or Legal Guardian 

Legal / Custody Information 

Please Note: If there are any legal issues, the agency requests copies of all legal documents to ensure that confidentiality and HIPAA practices are followed.  We will not disclose any information to any party without written informed consent of the client and/or legal guardian.  

Other Family Members (Siblings, Extended Family) Who Reside with Client 

Additional Pick-Up Person/Emergency 

Additional Pick-Up Person/Emergency 

School/Educational Placement

**Medications may or may not be provided during therapy hours, subject to the approval of the owner, and the availability of trained personnel and all state and federal regulations.                               

Supportive Services

Other Considerations

Consent for Treatment 

Your signature below indicates that you have received and read the information in this document and consent for Applied Behavior Analysis services. Consent by the client and/or legal guardians is required prior to the implementation of services. These policies have been fully explained to you and you fully and freely give your consent for the service to be implemented as proposed.