New Client Intake Forms with DERS-P/FAST
  • Welcome to Eclipse

    Dear Family, Starting therapy for your child can be exciting as well as overwhelming.  We will work together to achieve the goals you set for your child.  Included in this packet are a significant number of forms.  Please feel free to ask me any question you have via email or phone.  I am excited to embark on this journey with your family.  Sincerely, Rosalie 
  • An Overview of Eclipse Therapy Approach

    Mission:


    To ensure that every family has the opportunity to enjoy the simple pleasures of life: a peaceful family dinner, a quiet game of cards, a movie night out, or an event-free trip to the grocery store. Eclipse will provide consistent and exceptional behavior analytic services to children with disabilities.  Services are provided to optimize the child's progress towards their individualized goal. 


    Purpose: 

     

    The cornerstone of Eclipse Therapy is the understanding that any impairment or disability can have a debilitating effect on an individual and the family. With steadfast loyalty, Eclipse will strive tenaciously to increase the child’s abilities in an effort to improve the functioning of the child and furthermore increase harmony within the family.


    Our approach to working with each child: 

    • Is individually tailored to meet each child's unique needs 
      Is optimized to ensure your child is gaining skills as quickly as possible
      Is based on the most current research

    Our programming for autism addresses the major issues common in autism:

    • Understanding and using language 
    • Building broader social skills 
    • Communicating with and relating to peers 
    • Building emotional regulation skills 
    • Increasing flexibility and reducing rigidity
    • Increasing conceptual thinking and cognitive skills 

    Our programming for children with other disorders is individual tailored but will include these essential skills:

    • Building emotional regulation skills
    • Increasing distress tolerance
    • Increasing communicative abilities
    • Increasing conceptual thinking and cognitive skills 

    Eclipse Therapy’s trained therapists work one-on-one with each child closely monitoring responses in order to match the difficulty of the material and method of instruction to the child's ability level and rate of learning. All our therapists hold at least a high school diploma, have extensive training specifically in research supported treatments for autism spectrum disorders, behavior disorders, and the principles of Applied Behavior Analysis. Supervision of each child's program is provided by one of our BCBA with regular progress reviews. 

    In addition to the individual ABA program, parent training, programs to address problem behaviors, and a range of behavior analytic services are offered throughout our sessions. Our focus is on helping your child gain skills that are critical to your family and their functioning.  

    We provide behavioral assessments, parent & staff training, program supervision, and quality in home/school ABA programming. Each of our program supervisors is board certified by the Behavior Analysis Certification Board. 

    Please call 720-339-1309 for further information or clarification. 

    Instructions for this packet of information:

    This packet is rather lengthy, but it will help the Eclipse team better understand your child and the skills they need to acquire or maladaptive behaviors we need to help reduce.  Please be as detailed as you can.  If something does not apply to your child, please write NA.  

     

    We look forward to working with your family! Please do not hesitate to call or email with any questions or concerns.  

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  • Consent to Treat 

     I, the undersigned parent, person having legal custody or guardianship/authorized care provider of (the “minor”), do hereby authorize Rosalie Byrd Prendergast, MS BCBA, of Eclipse Therapy and any of the below Eclipse team members, LLC to provide and/or supervise behavioral health services. Such services may include, but are not limited to Behavioral Assessment, Behavioral Treatment, and Counseling Services. I understand this authorization may be revoked in writing at any time.

     

    Rosalie Prendergast, MS BCBA

    Katherine Thomas, MS BCBA

    Elias Frazier, Med BCBA

    Brittney Bonner, LMFT 

    Registered Behavior Technicians or Behavior Specialists

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  • Mandatory Disclosure

    Mandatory disclosure for each clinician available upon request. If for any reason you need to file a complaint or grievance below is information to do so.  At Eclipse we value your partnership and hope that you will come to us with any concerns that raise and provide us an opportunity to solve the problem.


    The Colorado Department of Regularly Agencies has the general responsibility of regulating the practice of licensed psychologists, licensed clinical social workers, licensed professional counselors, licensed marriage and family therapists, certified school psychologist, and unlicensed individuals who practice psychotherapy. The agency within the Office of Licensing Unlicensed Psychotherapist 1560 Broadway, Suite 1350 Denver, CO 80202, (800) 811-7648.

    Many of us are also regulated by the Behavior Analyst Certification Board. They can be reached at Behavior Analyst Certification Board 2888 Remington Green Lane, Suite C Tallahassee, FL 32308 850-765-0905

     

    Degrees: Rosalie Prendergast, MS BCBA:
    BA, University of Northern Colorado, 2004

      MS, Nova Southeastern University, 2009  

        Board Certified Behavior Analyst, 2009

      Unregistered Psychotherapist #12185, 2010


    3.  Agencies I report to:

    The Colorado Department of Regularly Agencies has the general responsibility of regulating the practice of licensed psychologists, licensed clinical social workers, licensed professional counselors, licensed marriage and family therapists, certified school psychologist, and unlicensed individuals who practice psychotherapy. The agency within Office of Licensing Unlicensed Psychotherapist 1560 Broadway, Suite 1350 Denver, CO 80202, (800) 811-7648.
    Many of us are also regulated by the Behavior Analyst Certification Board. They can be reached at Behavior Analyst Certification Board 2888 Remington Green Lane, Suite C Tallahassee, FL 32308 850-765-0905

    4. Client Rights and Important Information: 


    a. You are entitled to receive information from me about my methods of therapy, the techniques I use, the duration of your therapy (if I can determine it), and my fee structure. Please ask if you would like to receive this information. 


    b. You can seek a second opinion from another therapist or terminate therapy at any time. 


    c. In a professional relationship (such as ours), sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs, it should be reported to the State Board of Psychologist Examiners. 


    d. Generally speaking, the information provided by and to a client during therapy sessions is legally confidential if the therapist is a certified school psychologist, a licensed clinical social worker, a licensed marriage and family therapist, a licensed professional counselor, a licensed psychologist, or an unlicensed psychotherapist. If the information is legally confidential, the therapist cannot be forced to disclose the information without the client’s consent. 


    e. There are exceptions to the general rule of legal confidentiality. Some of these exceptions are listed in the Colorado statutes (see section 12-43-218, C.R.S, in particular). For example, I am required by law to report child abuse. There are other exceptions that I will attempt to identify to you, if feasible at the time, as situations arise during therapy. 

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  • Non-Discrimination Policy Statement


    It is the policy of Eclipse Therapy to provide services to all persons without regard to race, color, national origin, religion, sex, age, or disability.  No person shall be excluded from participation in, or be denied benefits of, and service; or be subjected to discrimination because of race, color, national origin, religion, sex, age, or disability.  


    Complaint of discrimination policy and procedure: this policy statement complies with Civil Rights Act, Title VI (45CFR part 80.7 B) and section 504 of the Rehabilitation Act of 1973 (45 CFR part 84.7 b.  If you feel that you have been denied a benefit or service because of your race, color, national origin, age, sex, disability, or religion you may file a Complaint of Discrimination with the facility administrator of Eclipse Therapy, either verbally or in writing.  A written response will be issued to you within 21 days of the complaint notice.  


    You may also file a complaint with an external agency.  If you choose to file your complaint in writing, you must include your name, address, telephone number, and a brief description of what occurred which led you to believe you were discriminated against.  If you need assistance, the facility administrator of Eclipse therapy will be able to assist you


    You may also file a complaint of discrimination by calling or writing the Department of Regulatory Agencies (DORA) Division of Civil Rights at (303)894-2997 or 1560 Broadway #1050, Denver, CO 80202    


    Please sign in receipt of this policy.

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  • AUTHORIZATION TO RELEASE INFORMATION

     

    I understand this release is voluntary and applies to all programs and services operated under the auspices of Eclipse Therapy LLC. I understand that my personally identifiable information (PII) may be protected by the federal rules for privacy under the Family Educational Rights and Privacy Act (FERPA), the Health Insurance Portability and Accountability Act (HIPAA), and/or other applicable state or federal laws and regulations. I understand that my PII may be subject to re-disclosure by the recipient without specific written consent of the person to whom it pertains, or as otherwise permitted. I also understand that the recipient may not condition treatment, payment, enrollment or eligibility on whether I sign this form, except for certain eligibility or enrollment determinations.  I understand that I may revoke this authorization at any time by notifying Eclipse Therapy LLC in writing, but if I do, it will not have any effect on any actions taken before receipt of the revocation. 

     

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  • Fee Schedule


    Behavioral Consultation with:

    Rosalie Byrd Prendergast, MS BCBA,

    $200 per hour plus $40 per hour traveled according to Google Maps. 

    Katherine Thomas, MS BCBA, Elias Frazier, Med BCBA,: 

    $160 per hour plus $40 per hour traveled according to Google Maps. 

    In Home/School Behavior Therapy, Masters level clinician:  

    $120 per hour plus $0.555 per mile traveled round trip according to Google Maps.

    In Home/School Behavior Therapy with RBT Level Clinician Pursuing Certification:  

    $85 per hour plus $0.555 per mile traveled round trip according to Google Maps.

    In Home/School Behavior Therapy with RBT Level Clinician: 

    $60 per hour plus $0.555 per mile traveled round trip according to Google Maps.

    Additional Charges applying to all services:

    These services may be necessary for your program and are billed at your clinician’s hourly rate. 

    Phone consultation lasting more than 15 minutes. 
    Written documentation (including progress reports and other forms of written communication) requiring more than 15 minutes
    Email messages require more than 15 minutes.
    Written or verbal communication with 3rd party payers (including insurance carriers, Community Centered Boards, etc.) requiring more than 15 minutes.
    Creation of individualized therapy materials such as, but not limited to books or stories requiring more than 15 minutes.
    Record review requiring more than 15 minutes.
    Other services a client may request require more than 15 minutes.

    Please Sign in your understanding of the Fees Charged by Eclipse Therapy LLC.  

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  • Payment Policy

    Eclipse Therapy LLC strives to offer the highest quality of care. Never will your care be contingent on your insurance or waiver coverage.  Considerable care has been taken to determine our rates. We want to assure you that our charges accurately reflect the complexity of care rendered and the skill and expertise required for optimal treatment. Our fees are comparable to those of other highly qualified specialists. Whether you have purchased insurance on your own, your employer has provided it to you, or you have qualified for a medicaid waiver, you are fortunate to have it and we will go the extra mile to help you maximize your benefits provided by your specific plan or waiver. As a courtesy to you, we will file with those plans to which we have been admitted as a provider (In Network) and when requested and we have not been admitted as a provider will complete the standard CMS1500 claim form for you to seek reimbursement through your insurer. When a service is covered, your insurance company usually only pays a percentage of the fee, and this varies from carrier to carrier and plan to plan. Your insurance is not designed to pay the entire cost of treatment, but it is intended to help cover a certain portion of the cost. 


    Please remember, however, the financial obligation for our services are between you and Eclipse Therapy, and is NOT between Eclipse Therapy and the insurance company.


    For clients choosing to private pay for services, you will be billed monthly via our QuickBooks online accounting system.  You will receive a bill between the 1st and 4th of the month following services.  Payment for these services is due back 30 days from receipt of the invoice from Eclipse Therapy LLC.


    Payment to our office is not contingent, nor dependent upon your insurance company. All account balances must be satisfied within 60 days of the date services were billed, after that time a re-billing fee of $10.00 may be charged to your account. If you have any questions regarding our financial policy, please do not hesitate to discuss them with us. 

    We accept cash, check, and bank transfers via QuickBooks online. 


    I understand and agree that I am responsible for the payment of all charges incurred regardless of any insurance coverage or other plans available to me. Additionally, I understand and agree to pay any and all collections costs and/or attorney’s fees if any delinquent balance is placed with an agency or attorney for collection, suit, or legal action. I also acknowledge that confidentiality is waived in matters involving collections and the sharing of information sufficient to pursue recovery of debts owed.

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  • HIPAA Email Consent

    VERY IMPORTANT! PLEASE READ!

    HIPAA stands for the Health Insurance Portability and Accountability Act HIPAA was passed by the U.S. government in 1996 in order to establish privacy and security protections for health information  stored on our computers is encrypted. Most popular email services (ex. Hotmail®, Gmail®, Yahoo®) do not utilize encrypted email. When we send you an email, or you send us an email, the information that is sent is not encrypted. This means a third party may be able to access the information and read it since it is transmitted over the Internet.
    In addition, once the email is received by you, someone may be able to access your email account and read it. Email is a very popular and convenient way to communicate for a lot of people, so in their latest modification to the HIPAA act, the federal government provided guidance on email and HIPAA  The information is available in a pdf (page 5634) on the U.S. Department of Health and Human Services website ‐ http://www.gpo.gov/fdsys/pkg/FR‐2013‐01‐25/pdf/2013‐01073.pdf 
    The guidelines state that if a patient has been made aware of the risks of unencrypted email, and that same patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email

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  • Assignment of Benefits

    1. I authorize payment of behavior health benefits to Eclipse Therapy LLC and/or clinicians at Eclipse Therapy LLC for these services and all future claims.  You should also understand you will be responsible for all non-covered services because of lack of authorization or for any other reason for denial. 
    2. I authorize the release of necessary medical information to process insurance claims.
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  • Permission to Photograph, Videotape, and Present

    I give permission and consent for Eclipse Therapy, LLC to take photos of my child and/or myself during the time my child is enrolled in services. I understand these photographs may be used in educational training presentations. 

     

    I give permission and consent for Eclipse Therapy, LLC to videotape and/or audio tape my child and/or myself during the time my child is enrolled in services. I understand these tapes will not be used outside the company and will be kept confidential. I understand that the tapes will be used for the purposes of developing more effective educational and therapeutic plans for my child, and also for the purpose of education and training for Eclipse Therapy, LLC and the family. 

     

    In addition to the above, I also give permission for Eclipse Therapy, LLC to use recorded video segments to present to parents and professionals for conferences and/or other training purposes. 

     

     

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  • Parent Guidelines and Policies

    Your cooperation on the following is greatly appreciated to assist us in working with your child at an optimal level:


    A parent or responsible adult must be in the home when therapy is being provided. 
    The therapist must wait 15 minutes if the child is not there at the therapy time and then is allowed to leave. You may be charged for the session and this is not billable to insurance. 
    The telephone numbers of all therapists will be given to parents so they can contact their therapist directly. Please do not call the therapists before 8 am and not after 9 pm. 
    Parents should contact a therapist 24 hours prior to the appointment if the parent knows they are going to cancel a session. If more than 25% of sessions are cancelled in a 3-month period, your child may lose their therapy slot. 
    Sickness. Please notify the therapist, as much in advance as possible, at least the night, before the scheduled session if you know that your child will not be able to participate in therapy the next day. Sickness includes, but not limited to the following: 
    Temperature above 100 
    Mumps                 
    Ringworm 
    Communicable Disease 
    Chicken Pox         
    Strep Throat 
    Foot/Mouth Disease             
    Measles                 
    Lice
    Vomit                                     
    Diarrhea                 
    Rash             
    Pink Eye 
    Parents are asked to use the same guidelines used in a school - if a child is too sick to attend school, he or she is too sick to participate in his/her therapy session. Therapy will resume as soon as the child's doctor clears him/her of being contagious or the remedy is completed. If a therapist arrives at the home and the child is sick, the therapist will not be able to work with your child.
    The therapist will call/text the family if they are going to be arriving more than 5 minutes late. 
    If parents cancel a session, these hours are not made up unless the therapist agrees to do so. 
    If a therapist cancels a session, these hours may be made up as soon as possible depending on the therapist availability. 
    Therapy schedules should be consistent to reduce scheduling errors.  Clearly there will be occasions like a doctor's visit where a session may be moved, but that should be a rarity rather than the norm.   
    A therapist cannot change appointment times without agreement with the family.
     In the case of snow or inclement weather: 
    Please listen to the radio for announcements of school closing for the district in which you reside. If the district schools are closed it is an indication that driving in that area presents danger Eclipse Therapy therapist should not report to work that day. 
    Since schools in the district are closed on inclement weather days, the time missed on those days can be made up at the discretion of the therapist and the family. 
    In case of an accident or unusual incident, the therapist should complete a form and inform the family and their supervisor within 1 business day. 
    Parents and therapists should be respectful and courteous to each other. Open communication between parents and therapists is essential to the establishment of a successful program for the child. All communication must be done in a courteous and respectful manner. If there are any problems or concerns, please contact the BCBA or BCaBA Supervisor immediately. 
    Parents are encouraged to share with therapists any information that may be helpful in getting to know their child and will enable them to work successfully with the child.
    Periodic videotaping of sessions may be helpful in assessing the progress of the child. Prior to a videotaping session, permission must be obtained by all parties involved and can be terminated at any time. Additionally, parents may request a copy of the taped session on a medium provided by them. 
    Eclipse Therapy feels that it is important to include all family members in therapy.
    Siblings are welcome to participate in therapy as long as they are a helpful addition to the session. 
    Parents are welcome and should participate in therapy sessions.
    Cheat sheets specific to your child will be created. Therapists and supervisors will go over these in detail and provide modeling and coaching for you on these strategies.  

     

    Information Related to Scheduling and Sessions

    Contacting us


    Given their many professional commitments, our technicians are often not immediately available by telephone or email. If you need to leave a message, we will make every effort to return your call or email promptly (within 24 hours with the exception of holidays and weekends.). If you are difficult to reach, please leave some times when you will be available. Because of the nature of the services we provide, we do not provide on-call coverage 24 hours per day, 7 days a week. In emergency or crisis situations, please contact your physician, or call 911 and/or go to the nearest hospital emergency room. 


    Services Offered


    We will provide services specifically designed to help your child, or if we cannot help we will provide you with referrals to other professionals who may be able to serve your child and his/her needs. Our behavioral services consist primarily of assessments, in home/school behavioral services, parent training, and on going collaboration with other professionals.  

    Your child will have an ABA technician or team of ABA technicians from Eclipse Therapy assigned to his/her case. Each technician has at least a high school diploma and has completed a 40-hour training in Applied Behavior Analysis and varying experience providing services to children with Autism and other behavioral/developmental difficulties. A Board Certified Behavior Analyst or Board Certified assistant Behavior Analyst oversees all cases. 

    ABA sessions are usually scheduled in two-three hour blocks. The research is clear that longer sessions result in greater retention and this makes scheduling more convenient for all parties. If this is not convenient for your family, please bring this up during the intake meeting. 

    Except in cases of emergency, 24 hours notice is required for all cancelled appointments. Payment for the appointment is required for all missed appointments not cancelled according to this policy. Insurance carriers are not responsible for miss-appointment fees. 

    We request that families give us at least two weeks notice on significant changes in their plans for in-home ABA sessions scheduling in order to facilitate consistency in service delivery. 

    The standard of care outlined in the ABA International's Revised Guidelines for Consumers of Applied Behavior Analysis Services to Individuals with Autism includes supervision of therapists on an ongoing basis, program consultation, program review, and program revision as services performed by a BCBA. These services are necessary for a program to meet minimum professional standards and are not optional. 

    Appointments


    Except for rare emergencies, we will see your child at the time scheduled. We understand that circumstances (such as an illness or family emergency) may arise which necessitates the occasional cancellation of appointments. In these cases, in order to avoid any misunderstanding, we ask that you speak to your therapist personally and give as much notice as possible to cancel or reschedule. This will allow us to best plan for the situation. 


    You may be charged the standard hourly rate (see fee schedule) for appointments missed or cancelled with less than 24 hours advance notice. Please note that insurance companies will not reimburse you for missed appointments and you remain responsible for these charges. 


    Cancellation and Session Attendance Policy

    Cancellations must be done no less than 24 hours prior to the scheduled session. If the client cancels more than two times without 24-hour notice, Eclipse Therapy can reduce or discontinue services. 

    Clients will participate in 80% of scheduled sessions per month. Otherwise, the client will have one month to reach 80% participation criteria, or Eclipse Therapy can reduce or discontinuation of services. Exceptions may be made if there are extreme medical conditions that require hospitalization, and a doctor’s note. 

    Clients will provide a minimum of 2 weeks notice for vacations lasting more than 3 days. If the client does not provide 2 weeks notice more than once, Eclipse can reduce or discontinue services. 

     

    Confidentiality, Records, and Release of Information

     

    Services are best provided in an atmosphere of trust. Because trust is so important, all services are confidential except to the extent that you provide us with written authorization to release specified information to specific individuals, or under other conditions and as mandated by Colorado and Federal law and our professional codes of conduct/ethics. These exceptions are discussed below. 

    To protect the client or others from harm


    If we have reason to suspect that a minor, elderly, or disabled person is being abused, we are required to report this (and any additional information upon request) to the appropriate state agency. If we believe that a client is threatening serious harm to him/herself or others, we are required to take protective actions which could include notifying the police, and intended victim, a minor's parents, or others who could provide protection, or seeking appropriate hospitalization. 


    Professional Consultations


    Behavior Analysts routinely consult about cases with other professionals. In so doing, we make every effort to avoid revealing the identity of our clients, and any consulting professionals are also required to refrain from disclosing any information we reveal to them. We will tell clients about these consultations. If you want us to talk with or release specific information to other professionals with whom you are working, you will first need to sign an Authorization that specifies what information can be released and with whom it can be shared. 

    Health Insurance


    If we file your insurance claims, you are responsible for co-payment. You are also responsible for all or any portion of the bill that your insurance does not cover or denies.  

    Professional Records


    You should be aware that, pursuant to HIPAA, we keep clients' Protected Health Information in one set of professional records. The Clinical Record includes information about reasons for seeking our professional services; the impact of any current or ongoing problems or concerns; assessment, consultative, or therapeutic goals; progress towards those goals, a medical, developmental, educational, and social history; treatment history; any treatment records that we receive from other providers; reports of any professional consultations; billing records; releases; and any reports that have been sent to anyone, including statements for your insurance carrier. 


    Patients Rights


    HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you. 

     

    Please sign stating you received the parent guidelines and policies.

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  • CHILD & ADOLESCENT INTAKE QUESTIONNAIRE

    Confidential

    The following questionnaire is to be completed by the child's parent or legal guardian. This form has been designed to provide essential information before your initial appointment in order to make the most productive and efficient use of our time. Please feel free to add any additional information, which you think may be helpful in understanding your child. Eclipse Therapy, LLC will hold information provided by you is strictly confidential and will only be released in accordance with HIPPA guidelines and as mandated by law. Please use the backs of the pages for additional information. 

     

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  • Leisure, Academic, and Social

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  • Challenging Behavior

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  • Emotions

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  • Language

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  • Sensory

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  • Motor Skills

  • Intervention Options

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  • Difficulties in Emotional Regulation-Parent Report

    Please indicate how often the following 36 statements apply to your child by selecting the appropriate number from the scale above (1 – 5) in the box alongside each item.

     

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  • Dear Parents and Guardians,


    We are conducting a research study around the development of Emotional Regulation Skills after the implementation of the frameworks in The Happy Medium Approach.  

    The above assessment will be used as a measure of progress and if you agree may be presented in a research paper or presented as part of professional development activities in the form of a pre, on going, or post treatment measure.  

     

    No identifying information will be used in any of these professional activities unless special permission is requested and given. 

     

    Consenting or not consenting to participation in this research will have absolutely no baring on the type of treatment your child receives under our care. 

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  • FAST

    Functional Analysis Screening Tool
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