Consent & HIPAA Forms

I, the undersigned parent or legal guardian, hereby consent to the provision of Applied Behavior Analysis (ABA) therapy and related behavioral services by Raven Behavior Analysis for my child or dependent.

I understand that services will be delivered by or under the supervision of a Board Certified Behavior Analyst (BCBA) and/or Registered Behavior Technician (RBT). I understand that treatment goals will be individualized and updated regularly based on my child's progress.

I acknowledge that I have the right to withdraw consent at any time, and that doing so will result in the discontinuation of services. I understand that participation in ABA therapy is voluntary.

I agree to actively participate in parent training and to implement strategies as recommended by the clinical team to support my child's progress.

How we use your information: Raven Behavior Analysis collects personal and clinical information solely for the purpose of providing behavioral health services, communicating with you, and coordinating care.

Who may access your information: Your information may be shared with treating clinicians, supervisors, and billing personnel as necessary to provide services. We will not disclose your protected health information (PHI) to any third party without your written authorization, except as required by law.

Your rights: You have the right to access your records, request corrections, and receive an accounting of disclosures. You may request restrictions on how your information is used or shared. You may revoke any authorization at any time in writing.

Safeguards: We maintain physical, electronic, and procedural safeguards to protect your PHI in accordance with HIPAA regulations.

For questions about our privacy practices, contact us at info@ravenbehavior.com.