Consent Form

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended treatment to be used so that you may make the decision whether or not to undergo any suggested treatment after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or assessment for any identified area(s) of need.
This consent provides us with your permission to perform reasonable and necessary assessment, testing, and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a treatment recommendation; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.
You have the right to discuss the treatment plan with your BCBA about the purpose, potential risks and benefits of any treatment. If you have any concerns regarding any assessment or treatment recommend by your BCBA, we encourage you to ask questions.
I voluntarily request a BCBA, to perform reasonable and necessary assessments and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior.
First Name*
Middle Name or Initial*
Last Name*
Date of Birth:*
Month
Day
Year
Address*
Street Address Address Line 2 City State ZIP Code
I Agree*
I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.
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