Consent for Video-Based Social Skills Group

I,
 
hereby give permission to my child:
 

Date of Birth:


to participate in a Video-Based Social Skills Group with close observation by a Supervising BCBA through
Gateway Pediatric Therapy, LLC. This virtual social skills group will take place via the HIPAA
compliant web platform, Google Meet. I understand that other clients from Gateway Pediatric Therapy
and their parent(s) will be present and participating in the Video-Based Social Skills Group. I understand
that my child and I will be interacting with other clients from Gateway Pediatric therapy and that I may
hear private and confidential information. I hereby agree to keep all client information confidential in
accordance with the Health Insurance Portability and Accountability Act (HIPAA). Through participation
in the group, I also recognize that other participants may come into contact with limited private
information about my 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:
 
  I consent for my child to be visually present via live video and audio for the duration of the virtual social skills group sessions.
  I understand that I must use a secure (non-public) internet connection to participate in the group.
  I understand that my consent for participation is voluntary and may be revoked at any time without repercussions.
  I understand that individuals present during the virtual social skills group will be made aware of my child’s participation in ABA therapy at Gateway Pediatric Therapy. Individuals present will have access to any information provided by me or my child during group activities.
  I understand that this group will not be recorded, and agree not to record any portion of the group activities in order to maintain confidentiality of all members of the group.
  I agree to maintain the privacy of other members of the group and will not discuss information disclosed during sessions with individuals outside of the group.

I have read and understand the information provided above and have had my questions answered to
my satisfaction. I am hereby giving consent for my child to participate in video-based social skills
group therapy with Gateway Pediatric Therapy.
 
Parent/ Guardian Name:
Date:
Signature