ABA Informed Consent - In-Clinic v4

ABA Informed Consent - In-Clinic

Phone: (248) 395-3777, Fax: (248) 395-3370, www.hchs.com, 28000 Woodward Ave., Ste 100., Royal Oak, MI 48067

To HealthCall Behavioral Services ABA Families,

As a provider of medical services, we rely on the recommendations of the Centers for Disease Control and Prevention (CDC) (linked below) and the Michigan Department of Health and Human Services (MDHSS), which is the governing body for autism services in Michigan.

If anyone has a temperature of 100 F or greater and/or any symptoms of COVID-19, they will not be allowed to remain in the center for therapy for a period of time determined by the Medical Director. Symptoms and risks associated with COVID-19 are included in the CDC link below.

If your child develops a fever or cough during therapy, you are expected to pick them up within 30 minutes of notification to minimize exposure to others; if you will be unable to pick them up in a timely manner, please cancel their therapy session in advance.

If you have any concerns or questions, please do not hesitate to reach out to your child’s BCBA.

Further information regarding COVID-19, including symptoms and risks, can be found here:

https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fprepare%2Ftransmission.html

By signing below, you are indicating that you have reviewed the information above, are understanding of the risks associated with COVID-19 and the risk mitigation efforts by HealthCall, and you are providing your informed consent for your child to receive ABA services face-to-face in-clinic.

Parent/Guardian Signature: *

clear

Parent First and Last Name: *

Child First and Last Name: *

Date: * +

v4 - 10.18.2023