Behavior Basics Treatment Consent Form

  • (Enter your own name if you are the client or your child’s name if he/she is the client)
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  • Assessment procedures may include

    • Review of documentation, records, and/or referral information
    • Interviews/questionnaires with client, parents, caregivers, and/or significant others
    • Direct observation/influence of client behavior in natural settings

    Treatment and/or Consultation may include:

    • Caregiver training in individualized parenting tools as appropriate
    • Implementation of behavior intervention plans and/or general recommendations to improve child behavior
    • In-home observation and support for appropriate caregiver application of behavior intervention plans
    • Role-modeling appropriate application of parenting tools during interactions with client
    • Collaboration with the provider of child welfare services, other service providers, and community entities.
  • (List names)
  • Client Signature (if client is an adult)
  • MM slash DD slash YYYY
  • *Parent / Guardian / Legal Custodian Signature Date (if client is child)
  • MM slash DD slash YYYY
  • *Required if client is a minor or legally incompetent. The Florida Statutes provide that DCF may consent to the medical care or treatment of any minor committed to it or in its custody when the person who has the power to consent as otherwise provided by law (i.e., the parents) cannot be contacted and the person has not expressly objected to such consent. Section 743.0645(3), Florida Statutes. DCF Rules further provide that DCF should make a reasonable attempt to contact the parents for consent, but if they are unsuccessful, they may consent as stated above. Rule 6C5-13.016 (3), Florida Administrative Code. If the parent has expressly objected, a court-order may be obtained.