Consent to Treatment

I acknowledge that I have received, have read (or have had read to me), and understand the “Information for Clients” brochure and/or other information about the therapy I am considering. I have had all my questions answered fully.

I do hereby seek and consent to take part in the treatment by Blooming Horizons LLC staff. I understand that developing a treatment plan with the BCBA and regularly reviewing the treatment plan that may help towards meeting the treatment goals are in my best interest. I agree to play an active role in this process.

I understand that no promises have been made to me as to the results of treatment or of any procedures provided during treatment.

I am aware that I may stop my treatment with Blooming Horizons LLC at any time. I will still be responsible for paying for the services I have already received. I understand that I may lose other services or may have to deal with other problems if I stop treatment. (For example, if my treatment has been courtordered, I will have to answer to the court.)

I know that I must call to cancel an appointment at least 24 hours before the time of the appointment. If I do not cancel and do not show up, I will be charged $100 for that appointment

I am aware that an agent of my insurance company or other third-party payer may be given information about the type(s), cost(s), date(s), and providers of any services or treatments I receive. I understand that if payment for the services I receive here is not made, Blooming Horizons LLC may stop my treatment.
My signature below shows that I understand and agree with all of these statements.

Signature of client (or person acting for client) - (jpg, jpeg, png, pdf, doc, docx only)

Date

Printed name

Relationship to client (if necessary)

Blooming Horizons LLC have discussed the issues above with the client (and/or his or her parent,
guardian, or other representative). Blooming Horizons, trained staff’s observations of this person’s
behavior and responses gives no reason to believe that this person is not fully competent to give informed
and willing consent.

Date

Copy accepted by client

Copy kept by Blooming Horizons LLC