Welcome to Personal Growth Services

Personal Growth Services is pleased to have you join us!

We pride ourselves in being an organization that is dedicated to providing families in the Central Connecticut area with the highest quality services. It is our mission to cultivate a nurturing and individualized learning environment for each and every child that we have the pleasure of working with. We look forward to getting to know you and your child!

Sarah Reiner MS, BCBA, LBA

Founder & Clinical Director

sarah@personalgrowthservices.com

Phone number: (860) 404-6360

www.personalgrowthservices.com

1. Appropriate and Compassionate Care

a. Under all circumstances and at all times patients have the right to appropriate and compassionate care. This care will not be denied on the basis of age, race, religion, color, national origin, ethnicity, sex, sexual orientation, gender identity or expression, physical or mental disability, marital status, socioeconomic status, or source of payment. Patients have a right to receive care that values the psychosocial, spiritual and cultural values that influence the way the patient views their condition.

2. Staff Identification

a. It is the right of the patient to know the identity and professional status of individuals providing them care. All staff will introduce themselves and explain their role to the patient.

3. Advance Directives

a. Patients retain the right to formulate advance directives and have their providers comply with these directives in accordance with the law.

4. Refusal of Treatment

a. Patients have the right to refuse treatment to the extent provided by law and to be informed of the medical consequences of said refusal. The results of the decision to refuse is the responsibility of the patient and/or their caregiver. When refusal of treatment prevents the provision of appropriate care in accordance with ethical and professional standards, the relationship with the patient may be terminated with reasonable notice.

5. Request for Service

a. Patients have the right to expect that within its capacity, Personal Growth Services, LLC will respond to a patient’s request for service. Evaluation and service will be completed based on needs indicated by the initial assessment

6. Access to the patient record

a. Patients have the right to read their record and obtain copies of their completed record upon request.

7. Confidentiality of records

a. Patients have the right to expect that communication and records regarding their care and services will be treated confidentially. Records will not be released to any party with the expectation of those authorized by patients or their legal representative.

8. Privacy- personal and information

a. Patients have the right to privacy in treatment and in caring for their personal needs.

9. Presenting a complaint

a. Patients and their family members or guardians have the right to present complaints to Personal Growth Services, LLC about any aspect of their care from Personal Growth Services, LLC.

10. Continuity of Care

a. Patients have the right to expect reasonable continuity of care, including discharge planning and discharge instructions. Patients can expect to be able to obtain information concerning continuing health needs, alternatives for meeting those needs and being involved in discharge planning.

11. Consent

a. Patients have the right to reasonably informed participation in decisions involving their care and service. Patients should not be subjected to any service or treatment without their consent or that of their legally authorized representative.

This section describes how medical/mental health information about you may be used or disclosed and how you can get access to this information. Please review this information carefully.

Personal Growth Services, LLC must maintain the privacy of your health information and provide you with this notice. You will be asked to sign a Release of Information Form. Once you have signed the Release of Information Form, Personal Growth Services, LLC staff members may use or disclose your Protected Health Information (PHI) for purposes of diagnosis, treatment, or obtaining payment. For example, to receive payment for our services, Personal Growth Services, LLC must provide information to the funding source being used.

Other permitted and required uses and disclosures that may be made without your consent, authorization, or opportunity to object:

● Abuse or Neglect: If any Personal Growth Services, LLC staff or employee suspects abuse or neglect of a patient they are mandated to make a report to the appropriate public authorities.

● Danger: If a Personal Growth Services, LLC staff member suspects that the patient is in imminent danger of harming themselves or someone else, they are mandated to make a report to the person at risk to the public authorities.

● Legal Proceedings: Personal Growth Services, LLC staff and employees may disclose PHI in response to a court order or subpoena or certain other legal proceedings. You have the following rights regarding PHI Personal Growth Services, LLC maintains about you.

● Right to Inspect and Copy: You have the right to inspect and request copies of information that may be used to make decisions about your treatment and care. Usually, this includes demographic and billing records but does not include specific case notes. You must submit a request in writing to inspect and receive copies of information. If you request a copy of the information, Personal Growth Services, LLC may charge a fee for the cost of copying, mailing, or other supplies associated with the request. Personal Growth Services, LLC must respond to your request within fifteen days of receipt.

● Right to Amend: If you feel that PHI about you is incorrect or incomplete, you may ask Personal Growth Services, LLC to amend and update the information. You have a right to request an amendment for as long as Personal Growth Services, LLC keeps the information. Your request for amendment must be in writing and must provide a reason supporting the request.

● Right to an Accounting of Disclosures: You have the right to request an Accounting of Disclosures regarding information that Personal Growth Services, LLC staff members have made about you. You must submit your request in writing to the Director of Services. Your request must state a period for the disclosures, which may not be longer than seven years and may not include dates before January 1, 2021.

● Right to Request Restrictions on Uses and Disclosures: You may request that disclosure of confidential information be limited. If Personal Growth Services, LLC is unable to agree to that restriction, we can discuss other options, such as referral to another provider.

● Right to Limit Reception of Confidential Information: For example, you may request that Personal Growth Services, LLC staff members only contact you at a certain telephone number or address. You do not have to give a reason for your request.

● Right to a Paper Copy of this Notice of Privacy Practices: You have a right to a paper copy of this signed notice.

Other uses and disclosure of PHI and any disclosure of Case Notes will be made only with your written authorization. After such authorization is given, you may revoke that authorization at any time from future use. This notice may be amended as needed to comply with federal, state, and professional requirements.

Notice of Privacy Practices Receipt Form

I, blanks* , have read and received a copy of the Notice of Privacy Practices from the staff of Personal Growth Services, LLC.

Parent/Caregiver's Name*

Signature*

Date*

Date

Financial Responsibility Agreement

Invoices: Personal Growth Services, LLC will invoice families with balances monthly. You will receive an invoice with the date of service, time of service, and service type. Invoices will be sent out electronically on a bi-weekly basis. If you would

like to receive a paper copy, please send an email to Sarah@personalgrowthservices.com.

Insurance: Personal Growth Services, LLC will ensure that any and all preauthorization, assessment, and progress reports are completed in a timely manner and submitted prior to any due dates to ensure ongoing and uninterrupted therapy

If a claim comes back as uninsurable, the full amount of services will be billed to the client after 6 Odays. If this is the case, it is your responsibility to contact the insurance company for reimbursement. You as the client are responsible for any charges or portions of charges that are not covered by your insurance company. Any paperwork necessary for contacting insurance is available upon request.

The parents/guardians of the child receiving services remain completely responsible for the full payment of all services, including late payment fees. We accept payment via cash, Venmo, or check. There is a $4 0 OOfee for all bank returned

Payment Agreement Please initial which type of payment terms you are requesting.

and authorize direct payment from my*

I elect to do private pay and will make direct payment to Personal Growth Services, LLC.I have Husky Insurance; all claims will be paid by the Husky- funding source.I have primary insurance coverage through Anthem and authorize direct payment from my insurance carrier to Personal Growth Services

I understand that during the term of this agreement, Personal Growth Services, LLC will provide ABA Therapy services, and the parent/guardian,will compensate Personal Growth Services, LLC a payment for the services as described in the terms and conditions specified. I understand all the fees and conditions as stated above. [If it becomes necessary for a third party collection, I agree to pay for all costs and expenses including reasonable attorney fees.]

Parent/Caregiver's Name*

Signature*

Date*

Date

Patient Name*

Parent/Caregiver's Name*

I represent that I am the legal parent/guardian/personal representative of the patient named above and I am not prohibited by law from releasing access to the requested information.

The information about the patient may include his/her: name, treatment modality (applied behavior analysis), age, duration of treatment, treatment plan, diagnosis, city and state of residence, photographs, and information about their life and how they came to Personal Growth Services, LLC or applied behavior analysis and their ongoing treatment. This information may also be used for internal purposes with other Personal Growth Services, LLC employees and staff. Personal Growth Services, LLC will not receive any direct or indirect payment from any third party, or on behalf of any third party, in exchange for the release of any information about the patient.

I understand the provision of health care treatment, payment for health care and health care benefits are not dependent on this authorization. I understand I am not required to sign this authorization, however the information will not be used or disclosed without authorization. I understand any information use or disclosed pursuant to this authorization may be subject to redisclosure.

I understand I have the right to revoke this authorization in writing, except to the extent information has already been released pursuant to this authorization at the time of the revocation. I can revoke this authorization by sending a written correspondence to the Director of Services as follows:

Attention: Director of Services

sarah@personalgrowthservices.com

This authorization will remain in effect until terminated by the undersigned.

I agree to pursue ABA treatment for my child, blanks* provided by a BCBA and designated ABA therapists. These services will be provided in home or via telehealth (if insurance permits), as requested by the parent(s)/caregiver(s), First Name* Last Name* .

I agree to take part in an ABA assessment conducted with my child, blank* . The results of the assessment will be put into the treatment plan, reviewed by the parent, and ultimately sent to the insurance company for approval of service hours.

I understand the associated risks and benefits to ABA treatment, as outlined by this document. I was offered the opportunity to ask questions about the risks and benefits of ABA intervention. Signature* (initials)

During the terms of this agreement Personal Growth Services, LLC will provided the following services:

Behavioral treatment services, which may include, but are not limited to: direct 1:1 instruction, a continuation of assessments, and modification of programs, a review of past and present data, completion of Functional Behavior Analysis (FBA) or Functional Behavior Analysis for problem behaviors, an update of Behavior Intervention Plan (BIP), and parent training.
Other services can be requested by are not included in this service agreement may include, but are not limited to:
- Program development
- Attendance to meetings or consultations with other professionals you have given authorization to
- Preparation of records of treatment
- Time required to perform any other service which you may request

Risks:

● ABA Treatment can be used to treat negative behaviors, and those behaviors may get worse prior to getting better. This is known as an extinction burst. Using this method to treat problem behavior will be discussed in-depth prior to use and will be agreed upon by both parties.

● Your child’s progress may vary depending on the skill, length of time, carryover, and teaching method. Data will be collected to determine teaching methodologies and next steps.

Benefits:

● ABA is an evidence-based science that is known as one of the most effective treatments for children with Autism Spectrum Disorder.

● ABA has been proven to treat a variety of problem behaviors and effectively teach new skills.

Parent/Caregiver's Name*

Signature*

Date*

Date

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Child's Name*

First NameLast Name

Welcome to Personal Growth Services

Client Rights and Notice of Privacy Practices

It is our policy at Personal Growth Services, LLC to preserve the rights of our patients and to facilitate the staff's awareness and partnership in preserving these rights.

CLIENT RIGHTS

HIPPA Compliance Form

ABA Treatment Contract