The purpose in seeking ABA Intervention is to identify challenging behaviors or skill deficits that require intervention to improve quality of life for the client by increasing opportunities for reinforcement, developing independent functioning abilities, improving communication, and increasing recreational repertoires.

Assessment
In ABA, behavior must be objective, observable, and measurable. The development of intervention occurs after formal and informal functional assessment(s). This helps to identify the function of challenging behavior and then create an intervention plan based on the principles of ABA. This formal and informal functional assessment includes but is not limited to, direct observations, interviews, questionnaires, rating scales, and formal assessments (VB-MAPP, Assessment of Basic Language and Learning Skills, PDD-Behavior Inventory, The Assessment of Functional Living Skills, Assessment, Evaluation and Programing System for Infants and Children). The client and individuals with direct contact with the client will participate in the assessment process.

Potential Benefits
Please note that it is impossible to guarantee any specific results regarding intervention plan goals. Together we will work to identify and achieve realistic outcomes.

• Improvements in communication, social relationships, and self-care.
• Increased participation in family and community activities

Safety Measures
Minimum risks are associated with behavioral interventions. As with all interventions, there is a risk the client will not respond, so the intervention will not work. Observations are completed at regular intervals and modifications occur when this occurs. Other risks include an increase in the behavior during the initial phase of implementation. This occurs most frequently but with consistency lessens rapidly. When this occurs, observations take place more frequently and plans are modified when necessary. If the client is posing a significant risk to self, others, or damage to property, as a last resort, Nonviolent Physical Crisis Intervention Techniques will be used to keep everyone safe.

Caregiver Involvement
For ABA services to be most successful, caregivers are required to attend regular meetings with their program manager and carryover interventions in the home environment. The frequency of meetings will be determined by your BCBA (Board Certified Behavior Analyst). You may be asked to take data sometimes to gather more information. It is important to attend these meetings and practice the strategies in the home environment to promote generalization of skills.

Right to Revoke Consent
The client can refuse or negotiate modifications of any suggestions they are not comfortable implementing. The client has the right to stop treatment at any time. If the client makes this choice, referrals to other therapists will be provided.

Treatment Termination
If at any time during treatment it is determined services cannot continue, a Transition to Termination notice can be provided to the client explaining the justification for this decision. Ideally, services end when treatment plan goals have been achieved. Additional conditions of termination can include:

• Professional ethics mandate that treatment continues only if it is clear the client is receiving benefit. If it is determined that the services are not proving to be clinically beneficial, ethical conduct requires a termination of treatment.
• Other legal or ethical circumstances may arise and lead to termination of treatment, such as the clinical expertise of the Consultant being inappropriate or insufficient for the client/individual receiving treatment. Please note: the BCBA will not diagnose, treat, or advise on problems outside the recognized boundaries of her competencies.
• Other situations that warrant termination may include drug abuse, disclosing illegal intentions or actions, inappropriate behavior during services, or failure meet parent participation expectations.

Your signature below will verify that you have read all the information in this Informed Consent and that you asked questions about anything you have not understood.

By signing, you freely acknowledge your willingness to undergo treatment using ABA methods:

I acknowledge that ABA involves potential physical, emotional, and mental risks, including property damage, personal injury, and emotional duress. I acknowledge that proper implementation of Applied Behavior Analysis requires ongoing training and support from a Certified Behavior Analyst, adherence to the treatment plan, and diligence in data collection.

 

Acknowledgement and Assumption of Risk

I acknowledge and agree to have my child (or the child under my care), receive ABA services from Pediatric Advanced Therapy. I acknowledge that there is some risk inherent in the use of the therapy equipment and I agree to assume such risk and indemnify and hold Pediatric Advanced Therapy and its staff, harmless from all losses and claims for any injuries or other damages occurring to myself, my child, or our belongings.

Purpose:
The purpose of this form is to obtain informed consent for the provision of virtual (remote) supervision services by Board Certified Behavior Analysts or Board Certified Assistant Behavioral Analysts (BCBAs/BCaBAs) at Pediatric Advanced Therapy, in accordance with the Behavior Analyst Certification Board (BACB) standards and HIPAA regulations.

Description of Services:
Supervision will be provided virtually using a secure, HIPAA-compliant video conferencing platform. Sessions may include:
- Real-time observation of service delivery by a Behavior Technician, in-person with the client
- Review of clinical documentation
- Feedback and performance evaluation
- Discussion of professional development and ethical practice

Technology Requirements:
Supervisors, supervisees, and clients/parents of clients (if applicable) must have access to:
- A secure internet connection
- A device with a webcam and microphone
- A private, quiet location to maintain confidentiality

Confidentiality and Privacy:
- All information shared during virtual supervision is confidential and protected under HIPAA
- Pediatric Advanced Therapy ensures that only authorized personnel are present during virtual supervision sessions
- Sessions will not be recorded without explicit written consent

Potential Risks and Limitations:
- Technical failures may disrupt sessions
- There may be limitations to observing certain behaviors or environmental factors through video
- Immediate physical intervention is not possible from the supervisor in a virtual setting

Benefits:
- Increased flexibility and scheduling options
- Enhanced access to supervisory expertise
- Continuity of supervision in remote or underserved areas

Consent:
By signing below, you acknowledge that:
- You have read and understood this consent form
- All questions regarding virtual supervision have been answered to your satisfaction.
- You/your child voluntarily agree to participate in virtual supervision with BCBA/BCaBAs at Pediatric Advanced Therapy
The main venue for my ABA treatment will be a Pediatric Advanced Therapy office. I understand that telehealth includes the practice of health care delivery, including consultation, treatment, transfer of medical data, and education using interactive audio, video, and/or data communications. I understand that telehealth also involves communication of my child’s medical and behavioral health information, both orally and visually, to other healthcare practitioners. I understand that I have the following rights with respect to telehealth:

(1) I have the right to withhold or withdraw consent at any time without affecting my (my child’s) right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I (my child) would otherwise be entitled.

(2) The laws that protect the confidentiality of my (my child’s) medical information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality including, but not limited to: reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. (See HIPAA Notice of Privacy Practices forms, provided to me, for more details of confidentiality and other issues.) I also understand that the dissemination of any personally identifiable images or information from the teletherapy interaction to researchers or other entities shall not occur without my written consent.

(3) I understand that there are risks and consequences from telehealth. These may include, but are not limited to, the possibility, despite reasonable efforts on the part of the BCBA/BCaBA, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; the electronic storage of my medical information could be accessed by unauthorized persons and/or misunderstandings can more easily occur, especially when care is delivered in an asynchronous manner. In addition, I understand that telehealth-based services and care may not yield the same results nor be as complete as face-to-face service. I also understand that if my child’s BCBA/BCaBA believes I would be better served by another form of service (e.g. face-to-face service), I will be transitioned to that service delivery with this group, if it is logistically possible for me and/or my child.

(4) I understand that I (my child) may benefit from teletherapy, but results cannot be guaranteed or assured. The benefits of telehealth may include but are not limited to: transportation and travel difficulties are avoided; time constraints are minimized; and there may be a greater opportunity to prepare in advance for sessions.

(5) I understand that I have the right to access my (my child’s) medical information and copies of medical records in accordance with North Carolina law. I have read and understand the information provided above, which has also been explained to me verbally. I have discussed it with my child’s BCBA/BCaBA, and all of my questions have been answered to my satisfaction.

(6) I understand that insurance companies may revoke the coverage/reimbursement for telehealth services at any point, and Pediatric Advanced Therapy is not responsible for these changes.

(7) I understand that it is required that the client is in the state of NC in order for sessions to be conducted due to state licensing requirements. I understand that if I am out of state, my session will be cancelled and rescheduled.