Applied Behavior Analysis for Children, Teens & Young Adults

1. Child / Client Information

2. Parent / Legal Guardian Information

*Custody Note: If parents/guardians are separated or divorced, please provide a copy of the current custody agreement or court order specifying decision-making authority for medical/educational matters.

3. Emergency Contact (if different from above)

4. Insurance / Billing Information

5. Developmental & Medical History

6. Presenting Concerns & Goals

7. HIPAA Authorization & Consent for Treatment

By signing below, I acknowledge that I have received and reviewed a copy of the Notice of Privacy Practices for ABA STEPS, which describes how my child's Protected Health Information (PHI) may be used and disclosed, and how I can access this information, in accordance with the Health Insurance Portability and Accountability Act (HIPAA).

I understand that I may revoke this authorization at any time by submitting a written request to ABA STEPS, except to the extent that action has already been taken in reliance on this authorization. I understand that treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization, except as permitted by law.

8. Consent for ABA Therapy Services

I hereby give consent for ABA STEPS to provide Applied Behavior Analysis (ABA) assessment and therapy services to my child. I understand that treatment may include direct observation, data collection, video/audio recording for supervision and training purposes (see below), and collaboration with other professionals involved in my child's care.

9. Hold Harmless & Release of Liability

In consideration of ABA STEPS providing Applied Behavior Analysis (ABA) assessment and therapy services to my child, I, the undersigned parent/legal guardian, agree to the following:

I acknowledge that ABA therapy may involve physical activity, behavioral intervention techniques, and close physical proximity between my child and clinical staff. I understand that, as with any therapeutic service, there are inherent risks involved, including but not limited to minor injury, emotional distress, or behavioral escalation during sessions.

I hereby release, discharge, and agree to hold harmless ABA STEPS, its owners, employees, contractors, and agents from any and all claims, liabilities, damages, costs, or expenses arising out of or in connection with the provision of services described herein, except to the extent such claims arise from the gross negligence or willful misconduct of ABA STEPS or its staff.

I further understand that this Hold Harmless Agreement does not waive any rights I may have under applicable state or federal law, and that ABA STEPS remains responsible for providing services in accordance with applicable professional, ethical, and legal standards of care.