Enroll your Child

Enroll your Child

Please fill out this form once your patient intake form (Step 1) has been reviewed and someone has already been in contact with you.
Date

MonthDayYear
Date
Contact Email (Very Important)*
example@example.com
Patient's Full Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MaleFemale
Diagnosing Physician*
Diagnosing Physician's Phone Number*
Please enter a valid phone number.
Diagnosing Physicians Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Documentation of autism diagnosis*

Cancelof

School information

Please provide a copy of the most current IEP
Name of School
Classroom size or ratio of students to teachers
Date Enrolled

MonthDayYear
Date
Date of recent IEP

MonthDayYear
Date
Inclusion/General EdMainstreamSDCNon-public School

Schedule

Please indicate the times the patient will be available for therapy
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Specific Times/Days

Informed Consent & Service Agreement
I, as a parent or guardian, give my consent for Path 2 Potential, LLC (P2P) to provide behavior analytic services to my child, in accordance to the ethical guidelines proposed by the Behavior Analytic Certification Board (BACB). I also understand that I may withdraw my consent and terminate treatment at any time and for any reason.

I understand that any information provided in this intake as well as any information obtained at any point during the interview process or course of treatment, is kept strictly confidential in accordance with HIPAA regulation guidelines and the law. I understand that state laws may require that confidentiality be broken under certain circumstances, specifically, if I am judged by the behavior analyst to be of danger to myself and/or others, gravely disabled, or if there is suspected child abuse.

I understand that Board Certified Behavior Analysts are bound to strict ethical guidelines of practice and that any issues of concern that may arise throughout the treatment process that are out of the behavior analyst's area of experience may result in referrals to a more appropriate agency or individual.

By signing below, you acknowledge the above statement of Informed Consent
I acceptI do not accept
Informed Consent Signature*

Clear
Date*

MonthDayYear
Date
Name*

First NameLast Name
More information
Please enter any special accommodations you wish to discuss or a reason if you choose to not accept the above

I authorize Path 2 Potential and/or staff to leave information pertaining to care and appointments by the following methods and will assumed responsibility to notify them whenever this information changes:

*Leaving blank means that you do not wish to be contacted through that mean
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Other
If you would like to have inform released to someone other than yourself and sign for services, please complete the following and list them below:
Name

First NameLast Name
Relation
Name

First NameLast Name
Relation
By signing below with your full name and date, you certify that the above information is complete to the best of your knowledge:
Authorization Signature*

Clear
Date*

MonthDayYear
Date
Name*

First NameLast Name
The following contains important information about Path 2 Potential Applied Behavior Analysis (ABA) professional services and practice policies. It is important that you read through this information carefully and ask any questions for clarification at any time. When you eSign this document, it will represent an agreement between you and Extraordinary Pediatric to provide ABA services. You, the consumer, reserve the right to withdraw at any time from these services.

Services Offered

Path 2 Potential abides by the Behavior Analyst Certification Guidelines for Responsible Conduct.
- Admission into ABA Therapy will be available for children, adolescents, and adults with an Autism or other Autism Disorder.
- If needed, Path 2 Potential will provide the client/family with contact information for other professionals who may be better able to assist with the needs of the client if Path 2 Potential is unable to meet specific treatment needs.
- Services will focus on the development and implementation of a functional behavior assessment and an ABA treatment plan.
- Path 2 Potential provides ABA services based on the client's current level of individualized needs.
- Upon discharge, recommendations will be provided as a way to support continued progress or address persisting concerns.
- The contents of both the assessment and treatment plan will be explained to the client and/or family.
- Path 2 Potential understands that this information is confidential, and will abide by established confidentiality policies and procedures.
Assessment, Preparation, and Participation

It is important for any individual to perform at their best during an assessment. Please let the Path 2 Potential ABA office know of any illness or changes in medication or diet that may necessitate an assessment to be rescheduled. Path 2 Potential also asks that our clients and/or families share information about an individual's preferences, dislikes, and needs that may arise during a clinical assessment.
Additionally, parent/caregiver participation is an expectation of service. Participation may include team meeting, data collection, and implementation and involvement in the implementation of recommended strategies.

Appointments

Path 2 Potential ABA Staff is committed to providing consistent, reliable service as scheduled and agreed upon by the client/family. Path 2 Potential proposes a preliminary set of hours for ABA services within the initial treatment plan, taking into consideration medical necessity, and results of the behavioral assessment.

Cancellation Policy

Path 2 Potential understands that circumstances, such as illness or family emergency, may arise which necessitate the occasional cancellation or appointments. Path 2 Potential's policy is for a client or family to contact the assigned behavior specialist/analyst directly to cancel or re-schedule session(s). Excessive cancellations by a client/family may result in termination of services, as consistency of the delivery of services as proposed in a treatment plan is critical. Path 2 Potential does ask that you attempt to give at least 12 hours notice when cancelling or re-scheduling an appointment.

Access to Records

Path 2 Potential does not release any client records unless there has been authorization on behalf of the client to do so. All clients must sign and Authorization of Exchange of Information form so that they may allow exchange of his or her records to referring physicians or other individuals who need access to their medical records with EP.

Communication

Path 2 Potential is committed to responding to any questions or comments regarding ABA Services in a timely manner. the Behavior Specialists, Behavior Analysts, and ABA Program Managers are committed to providing the best quality service to clients, which included timely, and professional communication.

Consent

By selecting "I Accept" below and providing your digital signature, it indicates you have read all the information above and consent to the terms.
ABA Service Agreement & Consent
The following contains important information about Path 2 Potential Applied Behavior Analysis (ABA) professional services and practice policies. It is important that you read through this information carefully and ask any questions for clarification at any time. When you eSign this document, it will represent an agreement between you and Extraordinary Pediatric to provide ABA services. You, the consumer, reserve the right to withdraw at any time from these services.

Services Offers

Path 2 Potential abides by the Behavior Analyst Certification Guidelines for Responsible Conduct.
- Admission into ABA Therapy will be available for children, adolescents, and adults with an Autism or other Autism Disorder.
- If needed, Path 2 Potential will provide the client/family with contact information for other professionals who may be better able to assist with the needs of the client if Path 2 Potential is unable to meet specific treatment needs.
- Services will focus on the development and implementation of a functional behavior assessment and an ABA treatment plan.
- Path 2 Potential provides ABA services based on the client's current level of individualized needs.
- Upon discharge, recommendations will be provided as a way to support continued progress or address persisting concerns.
- The contents of both the assessment and treatment plan will be explained to the client and/or family.
- Path 2 Potential understands that this information is confidential, and will abide by established confidentiality policies and procedures.
Assessment, Preparation, and Participation

It is important for any individual to perform at their best during an assessment. Please let the Path 2 Potential ABA office know of any illness or changes in medication or diet that may necessitate an assessment to be rescheduled. Path 2 Potential also asks that our clients and/or families share information about an individual's preferences, dislikes, and needs that may arise during a clinical assessment.
Additionally, parent/caregiver participation is an expectation of service. Participation may include team meeting, data collection, and implementation and involvement in the implementation of recommended strategies.

Appointments

Path 2 Potential ABA Staff is committed to providing consistent, reliable service as scheduled and agreed upon by the client/family. Path 2 Potential proposes a preliminary set of hours for ABA services within the initial treatment plan, taking into consideration medical necessity, and results of the behavioral assessment.

Cancellation Policy

Path 2 Potential understands that circumstances, such as illness or family emergency, may arise which necessitate the occasional cancellation or appointments. Path 2 Potential's policy is for a client or family to contact the assigned behavior specialist/analyst directly to cancel or re-schedule session(s). Excessive cancellations by a client/family may result in termination of services, as consistency of the delivery of services as proposed in a treatment plan is critical. Path 2 Potential does ask that you attempt to give at least 12 hours notice when cancelling or re-scheduling an appointment.

Access to Records

Path 2 Potential does not release any client records unless there has been authorization on behalf of the client to do so. All clients must sign and Authorization of Exchange of Information form so that they may allow exchange of his or her records to referring physicians or other individuals who need access to their medical records with EP.

Communication

Path 2 Potential is committed to responding to any questions or comments regarding ABA Services in a timely manner. the Behavior Specialists, Behavior Analysts, and ABA Program Managers are committed to providing the best quality service to clients, which included timely, and professional communication.

Consent

By selecting "I Accept" below and providing your digital signature, it indicates you have read all the information above and consent to the terms.
I AcceptI Do Not Accept
ABA Services Consent Signature*

Clear
Date*

MonthDayYear
Date
Name*

First NameLast Name

Credit Card on File Agreement
By signing the below agreement, you are giving Path 2 Potential, LLC (P2P) permission to automatically charge your credit card on file for your outstanding balances or any other patient(s) balances you have listed on this form at the time of service.
I authorize Path 2 Potential, LLC (P2P) to charge co-pays and outstanding balances on my account to the following credit card:
Co-Pays: Co-Pays are due at the time of the office visit.
Outstanding Balance: If your insurance provider has paid their portion of your bill or any other patient(s) you have listed below and there is still a balance owed, administration will notify you via email. If the balance due is not paid within 30 days, Path 2 Potential, LLC will charge the balance to your listed credit card. A copy of the charge will be mailed to you.

This in no way compromises your ability to dispute a charge or question you insurance company's determination of payment.

The credit card on file is to be used for the following patient(s).
*Note: This expires every year
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
This card will only be authorized for the use of the credit card holder, his/her minors, or any person(s) listed above. This agreement will expire for multiple users on an annual basis. If continued authorization if required, another credit card agreement can be issued or a manager can verbally authorize and document extension of this agreement.

By providing your digital signature below, you consent to the agreement stated above.
Credit Card on File Signature*

Clear
Date*

MonthDayYear
Date
I agree to the terms and conditions that if I have not paid any outstanding copay associated with services provided to me by Path 2 Potential before the 15th of each month the credit card on file will charged*
Name*

First NameLast Name

Consent for Functional Assessment
As a way to best serve the client, it is recommended that a Functional Assessment be conducted.
A functional assessment (FA) is an approach of collecting relevant data to:
- Identify behaviors that interfere with learning
- Identify environmental events which impact these behaviors
- Determine the cause/function of behaviors
An FA may include but is not limited to the following components:
- Interviews completed by client, caregiver, teacher, or therapist
- Information gathering tools
- Observation of client behavior
- Data collection
- Manipulating environment to determine the functions of behaviors
- Interventions to address behaviors, which focus on decreasing problem behaviors and teaching new, appropriate replacement behaviors
My eSignature below indicates my consent for this assessment and acknowledges:
- I have been fully informed and understand the request for an FA
- I understand that my consent is voluntary and may be revoked at any time
Consent for Functional Assessment*

Clear
Date*

MonthDayYear
Date
Name*

First NameLast Name
Questions or Concerns

Photo Use Release Form
I, the client, hereby grant and authorize Path 2 Potential, LLC (P2P) the right to take, edit, alter, copy exhibit, publish, distribute and make use of any and all pictures or video taken of me to be used in and/or for legally promotional materials, including, but not limited to, newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits and submissions to journalists, websites, social networking sites and other print and digital communications, without payment or any other consideration. This authorization extends to all languages, media, formats and markets now known or hereafter devised. This authorization shall continue indefinitely, unless I otherwise revoke said authorization in writing.

I understand and agree that these materials shall become the property of Path 2 Potential, LLC (P2P) and will not be returned.

I hereby hold harmless, and release Path 2 Potential, LLC (P2P) from all liability, petitions, and causes of actions which I, my heirs, representative, executors, administrators, or any other persons may make while acting on my behalf or on behalf of my estate.

If the person signing is under the age of consent, then this release must be signed by a parent or guardian.

By signing below, you acknowledge the above Photo Release Form.
I acceptI do not accept
Photo Release Signature*

Clear
Date*

MonthDayYear
Date
Name*

First NameLast Name
More Info
Please enter any special accommodations you wish to discuss or a reason if you choose to not accept the above

Release of Liability

This relates to all services that are requested where the guardian isn't present, or requests that are not within the guidelines of ABA Therapy
READ CAREFULLY - THIS AFFECTS YOUR LEGAL RIGHTS
In exchange for participation in the activity of Community transportation/activities, exercise, feeding, administration of any medication/supplements and any activity where a guardian (or a representative of the guardian) is not present. Organized by Path 2 Potential, LLC, of 58-12 Queens Blvd, Ste 5o, Woodside, New York, 11377 and/or use of the property, facilities and services of Path 2 Potential, LLC, I agree for myself and (if applicable) for the members of my family, to the following:
1. AGREEMENT TO FOLLOW DIRECTIONS I agree to observe and obey all posted rules and warnings, and further agree to follow any oral instructions or directions given by Path 2 Potential, or the employees, representatives or agents of Path 2 Potential.
2. ASSUMPTION OF THE RISKS AND RELEASE I recognize that there are certain inherent risks associated with the above described activity and I assume full responsibility for personal injury to myself and (if applicable) my family members, and further release and discharge Path 2 Potential, LLC for injury, loss or damage arising out of my or my family's use of or presence upon facilities of Path 2 Potential, LLC, whether caused by the fault of myself, my family, Path 2 Potential, or other third parties.
3. INDEMNIFICATION I agree to indemnify and defend Path 2 Potential, LLC against all claims, causes of action, damaged, judgements, costs or expenses, including attorney fees and other litigation costs, which may in any way arise fro my or my family's use of or presence upon the facilities of Path 2 Potential.
4. FEES I agree to pay for all damages to the facilities of Path 2 Potential, LLC caused by any negligent, reckless, or willful actions by me or my family.
5. CONSENT I consent to participation of my child/legal guardian in the activity of Community transportation/activities, exercise, feeding, administration of any medication/supplements and any activity where a guardian (a representative of the guardian) is not present, and agree on behalf of the minor to all the terms and conditions of the agreement. By signing the release, I represent that I have legal authority over and custody of the client.
6. MEDICAL AUTHORIZATION In the event of an injury to the above minor during above described activities, I give my permission to Path 2 Potential, LLC or to the employees, to treat and care for the client
BY PROVIDING YOUR ESIGNATURE BELOW, YOU STATE YOU HAVE READ AND UNDERSTAND THIS DOCUMENT. FURTHER, YOU UNDERSTAND THAT BY SIGNING THIS RELEASE, YOU VOLUNTARILY SURRENDER CERTAIN LEGAL RIGHTS.
I acceptI Do Not Accept
Release of Liability*

Clear
Date*

MonthDayYear
Date
Name*

First NameLast Name
Additional Information

General Consent for Treatment
Client Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Birth Date*

MonthDayYear
Date
Case Number
1. I hereby consent to the performance of routine evaluation and treatment for the above-named patient, as considered necessary in the judgment of the professional staff at Path 2 Potential. I understand that unless otherwise stated, this consent shall remain in effect for a period of not to exceed 18 months.

2. Information collected regarding the above-named patient is kept private and confidential within Path 2 Potential. Information regarding the above-named patient and care will only be shared with other individuals, agencies, or organizations with my written permission. I have been informed and understand that there are some circumstances in which confidentiality may not be maintained and information may be shared with others without my written permission. Such circumstances include but are not limited to:

● Suspicion or report of child abuse or neglect

● Suspicion or report of danger to the patient or others

● Information is court-ordered

● Laws require Path 2 Potential to release medical information related to certain disabilities that are considered an interest to public health

● Review by governmental oversight or accreditation agencies (e.g., audits, inspections, license renewals)

3. I hereby authorize the release of medical records on the above-named patient to any insurance companies or third-party payers that may authorize coverage or payment for services rendered to or on behalf of the above-named patient. Such records may include privileged information.

4. I understand I am responsible for any co-payments, deductibles, and/or outstanding bills not covered by my insurance or third-party payers. I agree to pay at the time of service or delivery of the bill unless other prior arrangements are made.

5. I have read and understood the Consent for Treatment form. I voluntarily and knowingly sign this consent form fully aware of its content.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Witness*

Clear
Date*

MonthDayYear
Date
How did you hear about Path 2 Potential?*
Should be Empty:

Enroll your Child

Family Information

School information

History of Services/Treatments

Current Services/Treatments

Spiritual/Cultural/Legal Concerns

Schedule

Informed Consent & Service Agreement

Services Offered

Path 2 Potential abides by the Behavior Analyst Certification Guidelines for Responsible Conduct.

Assessment, Preparation, and Participation

Appointments

Cancellation Policy

Access to Records

Communication

Consent

ABA Service Agreement & Consent

Services Offers

Path 2 Potential abides by the Behavior Analyst Certification Guidelines for Responsible Conduct.

Assessment, Preparation, and Participation

Appointments

Cancellation Policy

Access to Records

Communication

Consent

Credit Card on File Agreement

Consent for Functional Assessment

Photo Use Release Form

By signing below, you acknowledge the above Photo Release Form.

Release of Liability

BY PROVIDING YOUR ESIGNATURE BELOW, YOU STATE YOU HAVE READ AND UNDERSTAND THIS DOCUMENT. FURTHER, YOU UNDERSTAND THAT BY SIGNING THIS RELEASE, YOU VOLUNTARILY SURRENDER CERTAIN LEGAL RIGHTS.

General Consent for Treatment