Informed Consent for Services Balanced Child Behavior Associates is proud to offer in-person and online support services. Please complete and submit the form below prior to your child’s first session. Thank you! Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Child's Name *Child's School *Child's Date of Birth *Person Completing the Form *Relationship to Child *I confirm that I have legal custody of my child, named above, and am authorized to access their private medical information (HIPAA) and educational records (FERPA), specifically as related to behavioral support services provided by Balanced Child Behavior Associates. *YesNoHIPAA (Health Insurance Portability and Accountability Act of 1996) is United States legislation that provides data privacy and security provisions for safeguarding medical information. FERPA (Family Educational Rights and Privacy Act of 1974) is United States legislation that protects the privacy of students’ personally identifiable information.I understand that my child’s 1:1 or small group sessions will be guided by their individual treatment plan. Balanced Child Behavior Associates makes no guarantee that participation in behavioral support services will result in any specific outcomes. Every reasonable effort will be made to provide effective interventions using evidence-based practices. *YesNoStudents receiving services at school will be supervised by a designated staff member. I understand that students receiving services at home must be supervised by a parent or guardian. Balanced Child Behavior Associates cannot control the behavior of students, staff members, parents/guardians, nor other observers, and accepts no responsibility for their actions. *YesNoI hereby give consent for my child to participate in behavioral support sessions. I understand that I may revoke consent at any time by notifying Balanced Child Behavior Associates in writing. *YesNoI have read and understand this agreement and am authorized to execute this document on behalf of my child, named above.Parent/Guardian Name *Phone Number *Email *Date *Signature * Clear Signature Please use the mouse to sign your name. Then, click below to submit this form.Submit
