Harmony House LLC

Declination of Consent for Collaboration

For families who do not wish Harmony House to exchange information with outside schools, providers, or agencies.

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.

What declining means

Harmony House ABA will not share, obtain, or exchange information with external professionals or service providers, including schools, medical providers, therapists, or social service agencies.

Coordination of care between providers may be limited, which could impact the effectiveness or continuity of services.

This decision is voluntary, may be changed at any time, and will not affect your right to receive services.

Client information

Client name *

Client/guardian completing this form *

Email for your copy *

Declination

I DO NOT authorize Harmony House ABA to share, obtain, or exchange any information with external professionals or service providers. *

Anything you would like us to note

Signature

Typing your full name below acts as your electronic signature.

Client / guardian signatureDate

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