Skip to content
All forms

Harmony House LLC

Consent for Treatment

Informed consent for Applied Behavior Analysis services, including description of services, risks and benefits, confidentiality, and the right to withdraw.

Submitted securely to the Harmony House clinical team. Please do not use this form for emergencies — call 911, or 988 for a mental-health crisis.

Description of services

Harmony House ABA Services provides Applied Behavior Analysis (ABA) therapy designed to improve skills and behavior in individuals with developmental and behavioral challenges.

ABA therapy involves individualized assessment and intervention based on the principles of behavior analysis. Services may include skill-building activities, behavior modification strategies, parent and caregiver training, and progress monitoring and reporting.

Risks and benefits

Benefits: ABA therapy aims to improve communication, social skills, adaptive behaviors, and overall quality of life.

Risks: possible risks include frustration, temporary increases in challenging behaviors, or emotional discomfort. Our team works to minimize these risks and address concerns promptly.

Confidentiality

All personal and treatment information is kept confidential in accordance with HIPAA regulations, and shared only with authorized individuals as necessary for treatment and billing.

Right to withdraw & emergencies

You may withdraw consent at any time by notifying us in writing. Withdrawal may affect the continuation or effectiveness of therapy.

Where immediate treatment is necessary and consent cannot be obtained in advance, we will act in the client's best interests and seek retroactive consent as soon as possible.

Client information

Acknowledgment

Signature

Typing your full name below acts as your electronic signature.

Prefer paper? Download the PDF