CONSENT FOR PCM INTERVENTION

TO MAXIMIZE SAFETY AND REDUCE RISK OF HARM:
 
We are committed to keeping the client and staff safe at all times and reducing any potential risk of harm. BehaviorLink staff is trained and certified in Professional Crisis Management (PCM) which focuses on using prevention strategies and de-escalation to reduce the likelihood of crisis behaviors. Crisis behaviors are defined as continuous aggression, and/or continuous self-injury, or continuous high-magnitude disruption. In the event of a client displaying crisis level behaviors that put himself or others at harm, staff will implement PCM techniques to maximize safety. The use of PCM physical interventions are documented after each occurrence and are also described as part of a patient’s treatment plan.


 

CHILD NAME:

DOB:
 
 
 

PARENT NAME:

  

 I HEREBY AUTHORIZE THE STAFF OF {Company Name}, LLC TO IMPLEMENT PROFESSIONAL CRISIS MANAGEMENT PHYSICAL INTERVENTION TECHNIQUES AS CLINICALLY APPROPRIATE FOR THE ABOVE NAMED CHILD.

PARENT/GUARDIAN SIGNATURE:

Clear

DATE: