Consent of Treatment

hereby give consent to and authorize the agents and representatives of Gateway Pediatric
Therapy, LLC (“Gateway”) to treat my minor child:

I understand that Gateway engages in the practice of Applied Behavior Analysis (ABA)
therapy, and I hereby give consent and authorize the agents and representatives of Gateway to
provide treatment on an ongoing basis that may include, but is not limited to:

	An initial ABA assessment
	Functional Behavior Assessment
	Functional Analysis Behavior Intervention Plans
	Skill and Skill Deficit Analysis
	Daily One-On-One ABA Therapy
	ABA Supervision as provided by a BCBA, BCaBA, BC, and/or QBHP
	Parent Training as provided by a BCBA, BCaBA, BC, and/or QBHP
	Quarterly reassessments to measure progress

I understand what these services entail, and that additional information can be provided to me
upon request.

Name:
Relationship to Client:
Date
Signature