CSB Client Intake Package 2024

Client Intake Packet

This form is to be completed by the child’s parent or legal guardian so that Center for Success and Beyond (CSB) may learn essential information about your child for use in treatment planning. Center for Success and Beyond will ensure that any information provided by you is kept confidential according to HIPAA guidelines. Please contact the Behavior Analyst if you have any questions when completing this form.
Which location are you enrolling your child in? (Select One)*
Client Information:*

First NameLast Name
Client Birth Date*

MonthDayYear
Ethnicity:*
Legal Guardian/Caregiver 1:*

First NameLast Name
Legal Guardian/Caregiver 2:

First NameLast Name
Email:*
example@example.com
Relationship to Client:*
Please describe relationship:
Client Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does the client live with the person who is completing this form?*

YesNoOther
Mobile Phone Number:*
Work Phone Number:
Emergency Contact Name:*
Relationship to Client:*
Emergency Contact Phone Number*
Please enter a valid phone number.
Copy of License or Photo ID:*
Copy of Insurance Card Below:*
Insurance ID Number:*
Any secondary insurance? List secondary insurance, if so.
Upload a copy of your child’s official ASD diagnosis. (Note: If unable to upload full evaluation here, please email a copy to Contact@centerforsuccesstherapy.com. This is a requirement for all health plan providers.) *

Cancelof

General Information
Please list the goals for therapy below.*
Describe family composition (including siblings/ages, and others living in the home):*
Please list any significant legal/social events/stressors or previous trauma occurring in the home (e.g., parent illness, divorce).*
Please indicate your preferred days/times for therapy (weekdays/weekends). Note that behavior therapy is most effective when implemented continuously and frequently.*
Please indicate items that you child prefers (e.g., edible (food/drinks), tangible (toys, items), social (tickles, high fives), activities (swim, hide n seek):*

Medical History
Child’s Physician’s Name and Number:*

Physician’s NamePhone Number
Physician Fax Number:
example@example.com
Physician’s Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child’s Neurologist’s Name and Number:*

Neurologist Name:Number:
Neurologist Fax Number:
example@example.com
Neurologist’s Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Medical History Continued
Indicate child’s diagnoses, including age at diagnosis.*
Indicate any medical conditions/illnesses (e.g., asthma, recurrent ear infection) experienced by your child:*
Indicate any medications taken by your child, including dosage, time of administration (e.g., morning), start date, and purpose of medication.*
Does your child require a special diet? If so, please describe.*
Check any applicable conditions experienced by your child and provide descriptive information about the condition below.

AllergiesSleepEducational (e.g., processing disorder)VisionHearingFeedingSensoryOther
Descriptive information regarding selected conditions:

Educational History
Does your child attend school?*

NoYes, please list school below.
Does your child attend daycare?*

NoYes, please list daycare below.
If your child has attended school or daycare previous, please list name, begin date, and end date (month/year):*
Please indicate if your child currently receives supportive therapies (e.g., speech therapy, occupational therapy, etc). Please indicate the service, name of company, start date, hours/week, end date:*
Has your child received ABA therapy in the past? If yes, please indicate agency, time period (start and end date) and outcomes:*

Functional Behavior Assessment

Please list inappropriate behaviors that you would like to decrease (e.g., aggression (hitting others), elopement, tantrum, Self-Injurious Behaviors, etc.), along with the description of what it looks like (e.g., hitting, kicking, biting) and other characteristics, below. Then, complete one Functional Assessment Screening Tool questionnaire (end of this section) for each inappropriate behavior.
Challenging Behavior: *
Description of Challenging Behavior:*
How often does this behavior occur in a day?*
How often does this behavior occur in a week?*
Indicate the severity of the behavior (select one):*
What typically makes the child engage in this behavior?*
How do caregivers and others typically respond to the behavior?*
Indicate persons/activities with which behavior is most likely to occur:*
Indicate persons/activities with which behavior is least likely to occur:*

Challenging Behavior: *
Description of Challenging Behavior:*
How often does this behavior occur in a day?*
How often does this behavior occur in a week?*
Indicate severity of the behavior (select one):
What typically makes the child engage in this behavior?
How do caregivers and others typically respond to the behavior?
Indicate persons/activities with which behavior is most likely to occur:
Indicate persons/activities with which behavior is least likely to occur:

List Behavior and description of challenging behavior:
How often does the behavior occur (daily, weekly):
Indicate severity of the behavior (select one):
What typically makes the child engage in this behavior?
How do caregivers and others typically respond to the behavior?
Indicate persons/activities with which behavior is most likely to occur:
Indicate persons/activities with which behavior is least likely to occur:
Please indicate and describe any additional challenging behaviors, if any.

Does your child have difficulty with changes, such as when things are moved or when their schedule is changed? If yes, please describe.*
List any special skills, abilities, or strengths of your child.*
Does your child make eye contact with others?*
Does your child look or answer when their name is called?*
Cooperation with Adults: How easy is it to work with your child?*
Requesting: How does your child let their needs and wants be known?*
If you answered 3 or higher above, please describe the type of communication your child uses (e.g., picture exchange, words, or sign language).

Motor Imitation: Does your child copy the actions of others?*
Vocal Play: Does the child spontaneously say sounds and words?*
Vocal Imitation: Does your child imitate sounds or words?*
Matching to Sample: Does your child match different stimuli (e.g., objects, pictures, designs) to identical samples (e.g., matches a cup to a cup)?*
Receptive Communication: Does your child understand any words or follow directions (e.g., “sit down at the table”)?*
Receptive Labeling: Does your child label or verbally identify any items or actions when prompted (e.g., caregiver says, “what is it?” when pointing to a dog, or, “what is she doing?” when pointing to a person swimming)?*
Receptive labeling by function, feature, and class information: Does your child identify items when given information about those items? See examples of function, feature, and class below.*
Examples:
Function: child points to pen in a group of items when asked, “find something you write with”
Feature: child points to small block in a group of large blocks when told, “Point to the block that is small”

Class: child puts a toy pig into a group of animals, and a toy car into a group of vehicles when asked to put the item in the correct group

Caregiver Guidelines
The following guidelines are suggested for caregivers during applied behavior therapy. Caregiver participation in therapy is a must and required by funding sources.
- Caregivers are expected to participate in Family Guidance Meetings. Specifically, caregivers will be trained to implement their child’s behavior program, and data on the accuracy of their implementation will be collected.
- Caregivers should contact the therapist 24 hours prior to the appointment if they know they are going to cancel a session. If more than 20% of sessions are cancelled in a 3-month period, your child may lose his/her therapy slot.
- Sickness. Please give the therapist as much notice as possible prior to the scheduled session if you know that your child is sick. Sickness includes, but not limited to the following:
  - Temperature above 100
  - Communicable Disease
  - Foot/Mouth Disease
  - Vomit
  - Mumps
  - Chicken Pox
  - Measles
  - Diarrhea
  - Strep Throat
  - Lice
  - COVID-19
  - Rash
  - Flu
  - Pink Eye
- A therapist cannot change appointment times without agreement with the family and notification to Operational Manager and BCBA.
- The Operation Manager will give the family as much notice as possible before cancelling a session.
- Parents and CSB staff should be respectful and courteous to each other. Open communication between parents and CSB staff is essential to the establishment of a successful program for the child.
- If there are any problems or concerns, please contact the Behavior Analyst on the case immediately.
I understand and agree to the caregiver guidelines:
Signature*

Clear
Today’s Date:*

Informed Consent for Treatment

The undersigned acknowledges that Center for Success and Beyond, hereinafter referred to as CSB/CSB Therapy, is providing services to, or for the benefit of the above named client and is requiring, as partial consideration for providing said services, the execution of this Informed Consent for Treatment which is being executed by the undersigned as the natural parent, guardian, or other responsible party for the above named parities/client. The specific terms of this Informed Consent for Treatment are as follow:

❖ Center for Success and Beyond is providing services including, but not limited to behavior analysis services, behavior assistant services, assessments, program development, and treatment of the above named client.
❖ Center for Success and Beyond will provide the client services in a professional manner and will take every precaution within reason to insure the safety of the client.
❖ The undersigned herby acknowledges the potential risk of inadvertent injury to the client. Center for Success and Beyond has informed the undersigned that treatment strategies are often play-based or interactive in nature and accordingly, can potentially pose risk of unintended injury to the client.
❖ The undersigned hereby acknowledges the potential risks of injury based on the strategies implemented by Center for Success and Beyond and consents to the same despite the disclosed risks. Furthermore, the undersigned herby waives, on behalf of the undersigned as well as the patient, together with the heirs, devisees, or assignees of the undersigned or the patient, any and all liability for personal injury, physical, or otherwise, which may be incurred by the client as a result of the provision of services.
❖ The undersigned acknowledges and agrees that the execution of this form, and the promises and conditions as set forth herein, is partial consideration for the provision of services to the client by Center for Success and Beyond.
❖ The undersigned acknowledges and agrees that if the status of legal guardian should change, they will immediately notify Center for Success and Beyond, of the name, address, and telephone number of the person who has assumed guardianship of the client.
❖ The undersigned acknowledges and agrees that they have legal authority to consent to treatment, release of information, and all legal issues involving the below-named client. Upon request, I will provide Center for Success and Beyond, with proper legal documentation to support this claim.

By signing below I verify that I have read and understand the above Informed Consent for Treatment, agree to adhere to it, and wish to have Center for Success and Beyond provide services and that the provision of services will be contingent upon adherence to this agreement and full participation by the caregiver/guardian. If at any time there is not full participation and cooperation by the caregiver/guardian, I understand Center for Success and Beyond may terminate services following notice of 30 days. I also understand that I may discontinue services at any time and will be held accountable to pay for services rendered up to that point.
Signature

Clear
Date

MonthDayYear
Date

Please Read

Center for Success and Beyond, LLC and our staff CANNOT move forward in obtaining authorization for your child’s ABA services unless this form and the following form are filled in completely.
RELEASE OF INFORMATION

This authorizes the release or ability to obtain protected health information concerning the above named client. Health information may relate to my past, present or future physical or mental health condition, and the provision of my health care, or payment for my health care services.

• I understand that Center for Success and Beyond cannot guarantee that the Recipient will not re-disclose my health information to a third party. The Recipient may not be subject to federal laws governing privacy of health information.
• I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect my ability to obtain treatment from Center for Success and Beyond.
• I understand that I may revoke this Authorization in writing at any time, however, l cannot revoke authorization for action that has already been taken. I further understand that I must provide any notice of revocation in writing to the Business Office at the address (5505 W. Orem Dr., Ste #500, Houston, TX 77085).

A copy of this release shall be valid as the original.

THIS CONSENT EXPIRES ONE (1) YEAR FROM THE DATE SIGNED UNLESS OTHERWISE SPECIFIED.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

	Independent	Requires some assistance	Requires full assistance
Toileting
Feeding
Dressing
Tooth brushing
Hair brushing
Community Safety
Home Safety

Client Intake Packet

General Information

Medical History

Medical History Continued

Educational History

Functional Behavior Assessment

Caregiver Guidelines

Please Read