This Parent Consent Agreement hereinafter referred to as “Agreement” is entered into
between Early Autism Services, LLC (“EAS”) and Payor Full Name
(“Parent”) [Parent Name Provided Below] dated the [Date Provided Below].
Client Full Name [Child Name Provided Below] (“Child”) has been authorized to
receive intensive behavior modification services (“Services”) from EAS. In order to
assure that your child and family receive prompt, professional and competent Services
from EAS the following guidelines have been developed.
1. During the first week of providing Services, we request that you become
available to “shadow” Consultant and/or Therapist until they become familiar
with your child and his/her schedules as well as get an intimate knowledge on
the nature of his/her behaviors.
2. Please monitor your Child’s Services for the first couple of weeks and inform EAS
immediately should there be a mismatch between your child and the Consultant
and/or Therapist assigned to work with him/her.
3. Data will be collected throughout the entirety of the session and the last 15 to
20 minutes of your Services will be dedicated to filling out the daily notes in the
Program Book. The collection of data is mandatory for the provision of Services.
The Program Book shall be provided by EAS. Additionally, the fit between a
child’s therapeutic needs and the program’s services is determined on an
individual case basis by both the parent/guardian and the consultant. EAS
provides services exclusively to children and adolescents under the age of 18
and their families.
4. Please allow an area where we can keep the Program Book in your We require
the Program Book for the collection of our data. Only the Consultant, Therapist,
any other designated agent of EAS, and/or parent will have access to the
5. The Parent has the responsibility to inform the Consultant and/or Therapist of
his/ her child’s relevant medical conditions; infectious diseases; allergies to
medications and other substances; and any other relevant information in order
to assist in developing a treatment plan.
6. The Parent agrees to engage and participate in a family education program for
the Child’s care, treatment, and needs.
7. The Consultant or Therapist shall only provide Services to the Child designated
in this agreement.
8. The Child’s parent or an appointed guardian shall be present at all times Services
are provided to the Child by EAS.
9. If the parent will be away for any reason for any length of time and the Parent
has designated a guardian; another family member and/or authorized agent
(“Responsible Party”) to be present during the time when the Child is receiving
Services by EAS, EAS requests that you advise the Consultant or Therapist at
least one week in advance, so the Consultant or Therapist can make the
10.Video or audio recording of therapy sessions, team meetings, or in any other
instance that involves personnel associated with EAS without the written
consent of EAS and the representative of EAS being recorded is prohibited. Any
recording must be done with the written consent of the individual therapist being
Additionally, an authorized representative of EAS must also give written consent
of any recording that takes place.
11.Representatives of EAS are prohibited from taking pictures, video, or audio
recordings of a child or any other family. Additionally, EAS representatives are
prohibited from posting any information to the Internet that pertains to a child’s
ABA program. If you have a concern about the actions of any individual affiliated
with EAS that pertain to this policy, please contact EAS immediately.
12.The parties understand that the Child's treatment and Services may change due
to the Child's development and response to EAS shall discuss any additional
treatment requirements and/or next level of Services with Parent prior to
transitioning such treatment and Services to the Child.
13.Community outings will be limited to settings that do not require money (i.e. park,
shopping mall, library, bookstore). When EAS takes the Child on a community
outing as defined herein, the Parent and/or Responsible Party (as defined in Paragraph 9) shall be present. During the community outings, the Parent and/or
Responsible Party are in charge and responsible for the Child’s well-being, care
and are and to monitor the Child accordingly. Parent and/or Responsible Party
hereby waives, releases, and discharges EAS, its owners, employees, and/or
authorized agents from any and all liability, loss, cost, claim, damage, injury
and/or cause of action of any kind arising out of the Child’s participation in a
community outing. In addition, Parent and/or Responsible Party shall indemnify
and hold harmless EAS, its owners, employees, and/ or authorized agents from
any and all such liabilities or claims made as a result of the Child’s participation
in the community outings.
14.Physical intervention by a therapist in the presence of aggressive behavior may
be necessary at some point during a child’s program. The use of physical
intervention is only considered when all other strategies have been exhausted.
Furthermore, physical intervention or restraint will only be used if there is concern
for the immediate safety of the child or the therapist. Please call your consultant,
Mareiko Au, or Vincent Scarlata with any questions or concerns about EAS’s
policy on physical intervention.
15.The Services not included in this Agreement are as follows:
• The Consultant and/or Therapist shall not, under any circumstances, drive
the Child in his/her private vehicles;
• The Consultant and/or Therapist shall not administer medications to the
• The Consultant and/or Therapist shall not, under any circumstances,
accompany the family and the Child on vacations;
• The Consultant and/or Therapist is only responsible for the Child assigned
to him/ her and may not be given other siblings and /or family members to
• No money shall exchange between the Consultant and/or Therapist and
the Parent; and
• The Consultant and/or Therapist shall not act as a babysitter for your Child.
16.Under no circumstances will EAS support parents or the Consultant and/ or
Therapist engaging in dual relationships that compromise the guidelines and
integrity of EAS (i.e. parents will not promote and/or engage the Consultant
and/or Therapist in personal relationships and/or professional opportunities
outside of EAS services). Furthermore, at all times the parent(s) must respect boundaries of the Consultant and/ or
17.The Consultant arranges all schedules in coordination with parental input. At the
onset of services should you require changes in the schedule, please notify the
Consultant. The Therapist is not authorized to make any schedule changes.
18. EAS's owner is Benjamin Wessels. If you have any questions or concerns about the
quality of services, personnel (including Consultants or Therapists), the program, or
of the agency in general during the time of your services, please contact either
Mareiko Au or Vincent Scarlata at [email protected]
19.Upon termination of this Agreement, EAS shall advise Parent of the Child's prognosis
and information concerning the Child's continuing care and EAS will make available
all necessary documentation and treatment records for continuity and coordination of
care with subsequent providers. At the request of a parent/ guardian, EAS will contact
subsequent providers with relevant information to ensure continuity of care.