Client Consent Packet 2023 – Initial and annual

This Client Consent Packet Template is designed to facilitate clear communication and obtain necessary consent from clients. It includes initial and annual consent forms, detailed service agreements, fee schedules, and informed consent for emergency care, telehealth, and media recording. Emergency contacts, privacy practices, and acknowledgment for receiving the caregiver handbook are also integrated, ensuring comprehensive compliance and understanding between ABA practices and their clients. Perfect for customization, this template streamlines the consent process, making it straightforward and transparent.

Contents

Initial consent package 3

• Instructions for this packet 4

• Welcome 5

• SERVICE AGREEMENT 6

• Attachment A – Fee Schedule 11

• Consent for Emergency Medical Care 17

• Informed Consent for Telehealth Services 18

• Consent to Photograph/ Videotape/ Audiotape 20

• Emergency Contact Card 21

• Consent for the Use of Emergency Physical Intervention 22

• NOTICE OF PRIVACY PRACTICES 24

• Acknowledgement of Receipt of Notice of Privacy Practices 26

• Acknowledgement of Receipt of Caregiver Handbook 27

Annual consent package 28

• Instructions for this packet 29

• SERVICE AGREEMENT 30

• Attachment A – Fee Schedule 35

• Informed Consent for Treatment 36

• Consent for Emergency Medical Care 41

• Informed Consent for Telehealth Services 42

• Consent to Photograph/ Videotape/ Audiotape 44

• Emergency Contact Card 45

• Consent for the Use of Emergency Physical Intervention 46

• Acknowledgement of Receipt of Caregiver Handbook 48

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Downloads available for use by purchasers and customers only. You agree not to distribute this document for use by other organizations or programs, in whole or in part, without the prior written consent of Partners Behavioral Health.

Use of downloads does not constitute a relationship between the purchaser and Partners Behavioral Health, nor does Partners Behavioral Health assume any liability for the outcome of implementing this in your agency or program.

By accepting downloads, you agree to be bound by these restrictions and limitations.