By clicking Yes(and providing your signature below) you are ensuring you are the legal guardian and have the authority to make decisions and provide consent for the client that is applying for services. In addition you are giving Blessed ABA Therapy Service permission to:

• Directly request comprehensive diagnostic evolutions and referral documentation from health care providers and school personnel

• Begin the assessment and behavior plan development process.

• To use or disclose your protected health information(PHI) for treatment, payment and health care operations purpose.

• By signing here, you consent to the utilization of your signature and the information provided in this application for the purpose of generating the documentation required for obtaining authorization with your insurance provider.