Pre-Intake Questionnaire

Enrollment Packet
Dear Parents/Legal Guardians, Thank you for your interest in Community School, a Division of Holy Angels. Our mission is to positively impact the life of each child through our unparalleled commitment and desire to see our learners reach their greatest potential.

Educational and therapeutic services are aimed at developing your child’s communication skills, increasing social interactions with others, expressing and coping with emotions, and developing self-regulation strategies.

Our educational philosophy is grounded in the principles of Applied Behavior Analysis (ABA). We believe that ABA teaches people HOW to learn most effectively, while education informs WHAT to teach. The two disciplines complement one another, maximizing the learning opportunities our learners encounter.

This packet MUST be completed PRIOR to your child’s first day of school and/or ABA therapy at Community School. Your child’s file will become active once this packet and all additional required documents have been received and reviewed by our team.

If you have any further questions or concerns, please contact us

Toni Black Administrative Assistant

Phone: 318-797-8500 ext. 159

Fax: 318-629-2735
Name
ID#
Date Reviewed

Part A: Completed by all applicants*

	Reviewed	Completed
Autism-specific Diagnostic Assessment (p. 1)
Prescription for ABA Services (p. 1)
Medical Evaluation (Well Child Check) (p. 1)
Copy of Insurance Cards (FRONT & BACK) (p. 1)
Enrollment Application (p. 2)
Medical History (p. 3)
Emergency Plan / Information (p. 4 - 5)
Insurance Information (p. 6)
History of Therapies (p. 7 - 8)
Parent/Caregiver Intake Questionnaire (p. 9 - 16)

Part B: ONLY completed by applicants interested in ABA or OT therapeutic services

	Signed or Initialed
General Information About Services (p. 17 - 19)
Orientation to Services (p. 20)
Mission Statement / Program Description (p. 21)
Client’s Rights & Responsibilities (p. 22 - 23)
Consent for Treatment & Recipient’s Rights (p. 24)
Authorization to Release Information (p. 25)
Authorization to Bill Insurance (p. 26)
Human Rights Notification (p. 27)
Client Grievance Procedures (p. 28)
Notice of Privacy Practices (p. 29)
How to Contact your Service Providers (p. 30)
Privacy of Information Policies (p. 31 - 33)
Confidentiality Act – Abuse-Reporting Protocol (p. 34)
Freedom of Choice of Provider (p. 35)
Functional Behavior Assessment (FBA) Consent Form (p. 36)
Transportation Authorization (p. 37)
Permission to Photograph/Videotape/Audiotape (p. 38)
Consent for Participation in Swim Program (p. 39)
Telehealth Practices & Protocols (p. 40 - 42)
Certification & Licensure Board Information (p. 43)
Informed Consent for Restrictive Procedures (p. 44)
HIPAA Service Agreement & Consent Form (p. 45 - 47)
Financial Agreement (p. 48 – 49)

Thank you for your patience and diligence. We’ll get through this part. Remember, it is important to know and understand what you are agreeing to. Partnership requires clear understanding. Ask all the questions!

History of Developmental Conditions or Mental Health Concerns in Other Family Members: Family History of: *

	Yes	No	If yes, whom
Depression
Anxiety
Substance Abuse
Autism
Bi-polar Disorder
Schizophrenia
Learning Disabilities
Developmental Delays
Other

Evaluations/ Assessments/ Required Documents

The following reports are REQUIRED as a part of your enrollment application.
Autism-specific Diagnostic Assessment: This evaluation can be completed within the Psychological Evaluation or the Speech/Language Assessment. This includes the use of any of a variety of diagnostic tools (CARS, ADOS, etc.), which are designed to evaluate specifically for the symptoms of autism spectrum disorder. Please include all previous evaluations as well.

Cancelof
Prescription for ABA Services: Call your child's pediatrician & request they fax the ABA prescription to CS at (318) 629-2735.

Cancelof
Medical Evaluation (Well Child Check): This is an examination by a licensed physician. This evaluation must be completed within the last 12 months.

Cancelof
Insurance Card(s): A copy of the FRONT and BACK of ALL insurance cards must be emailed, mailed, or fax.

Cancelof
Evaluations/ Assessments/ Required Documents: Please include any additional reports below if applicable. Only the most recent evaluations are needed.

Cancelof
Comprehensive Speech/Language Evaluation: This is an evaluation by a licensed Speech/Language Pathologist.

Cancelof
Occupational Therapy Evaluation: This is an evaluation completed by a licensed occupational therapist.

Cancelof
Physical Therapy Evaluation: This is an evaluation completed by a licensed physical therapist.

Cancelof
Feeding Therapy Evaluation: This is an evaluation completed by a licensed occupational therapist or speech and language pathologist.

Cancelof
Individualized Education Plan: All Individual Education Plan (IEP) or Individual Family Service Plan (IFSP) are requested, as these documents demonstrate learning patterns and skill acquisition across time.

Cancelof
Previous evaluations and assessments conducted by medical and therapeutic practitioners include important information needed to request Authorization of ABA Services from insurance providers and help inform treatment planning. Individualized treatment plans will be developed by the Community School interdisciplinary team based on a records review, direct observation of the learner, and a parent / caregiver interview. Community School is not required or obligated to follow IEPs or IFSPs developed by public school providers.
Parent/Guardian Signature: *

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Name:*

First NameLast Name
Relationship Child:*

Diagnostic Information
What is your child’s primary diagnosis?*
Date your child was first diagnosed?*
Licensed Mental Health Professional / Physician who gave diagnosis:*
Agency Name: *
Phone Number: *
Fax Number:
Date of Last Evaluation (include copy of evaluation):
Current: Yes or No*
Last 12 months: Yes or No*

Medical History

Primary Care Provider
Name:*

First NameLast Name
Title:*
Clinic Name: *
Phone Number:*
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Agency Adress: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Last Seen: *
Anticipated Next Visit: *

Medical History*

	Yes or No
Hospitalizations, Yes or No, if Yes, please describe and provide a date:
Surgery, Yes or No, if Yes, please describe and provide a date:
Seizures, Yes or No, if Yes, please describe and provide a date:
Head Injuries/Loss of Consciousness, Yes or No, if Yes, please describe and provide a date:
High Fevers Yes or No, if Yes, please describe and provide a date:
Other

Prior Medical Evaluations*

	Date:	By Whom:	Reason/Result:
Well child check/annual physical
Social Emotional screening
Developmental screening
Hearing
ENT/Allergies
Neurology
Genetic Testing
Other:
Are immunizations current? ☐ yes ☐ no If no, describe reason:

Emergency Contact Information (Page 1 of 2)
Client's Name *

First NameLast Name
Emergency contacts other than parents/guardians:
Contact #1: Name*
Relationship: *
Phone Number*
Please enter a valid phone number.
Contact #2: Name*
Relationship: *
Phone Number*
Please enter a valid phone number.

The following people are allowed to pick up:

	Name	Relation to Child	Phone Number
Person Number 1
Person Number 2
Person Number 3
Person Number 4

The following people are restricted from contact with your child:

	Name	Relation to Child / Additional Comments or Notes
Person Number 1
Person Number 2
Person Number 3
Person Number 4

**Please note a separate client release form needs to be filled out for the individuals noted for the emergency contacts and those who can pick up your child. See client release of information form at the end of the enrollment packet. **

Emergency Plan / Information (Page 2 of 2)
Child's Dentist
Name of Dentist: *

First NameLast Name
Name of Clinic: *
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Physician
Name of Physician *

First NameLast Name
Name of Clinic: *
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Medications

(include additional sheets as necessary)
Does child take medications? ☐yes ☐no - If yes, list below*

	Medication	Dosage	Frequency	Reason for Use	Administered by Partners Staff? Yes or No
Person Number 1
Person Number 2
Person Number 3
Person Number 4

Allergies (include additional sheets as necessary):
Does the child have allergies? Yes or No If yes, explain type of allergy and reaction, including any medication.*

YesNo

	Allergy	Reaction
Medicine 1
Medicine 2
Medicine 3
Medicine 4
Medicine 5
Medicine 6
Medicine 7
Medicine 8
Medicine 9
Medicine 10

Emergency action plan for seizures & allergies:
Child has a seizure history: Yes or No
Emergency Plan

911 will be called if:

The seizure lasts longer than _____ minutes (if the seizure lasts longer than 5 minutes

911 will be called unless a note is provided from the doctor stating otherwise)

Your child is having difficulty breathing.

Vomitus is aspirated

A significant injury occurs during the seizure

Status epilepticus occurs (continuous seizure)

Describe your child’s typical seizure. What do you want Community School staff to do (other than routine first aid) if your child has seizure while at the center?

Type a label
Call Parent when: *
Call Physician when: *

Insurance Information
Client Information:*

First NameLast Name
Medicaid (Choose “N/A” if your child does not have Medicaid) Your Child’s Medicaid Managed Care Organization (MCO):*

Louisiana Healthcare Connections (LHCC)AetnaAmerigroup LouisianaAmeriHealth CaritasHealthy HumanaHealthy BlueN/AOther
Your Child's Medicaid Number: *
Has your child completed the SMRT process? Yes or No*
Primary Insurance
Name of Primary Insurance Company:
Contract #
Group #
ID #
Insurance Policy Holder:
Relationship to Client:
Date of Birth (Insured):
Employed by:
Occupation:
Business Phone:
Business Address:
Secondary Insurance
Name of Secondary Insurance Company:
Contract #
Group #
ID #
Insurance Policy Holder:
Relationship to Client:
Date of Birth (Insured):
Employed by:
Occupation:
Business Phone:
Business Address:

	Age or N/A
Babbling
Combing Words
Rolled Over
Crawling
Walking
Use Utensils
Dry throughout the night
Brush teeth independently
Fasteners on clothing
Bathing self
Washing hands
First Word
Complete sentences
Sitting unsupported
Standing
Eating Table foods
Toilet trained
Sleeps throughout the night
Dress self
Tying Shoes
Brushing hair

General Information About Community School Services

An Overview of Applied Behavior Analysis
ABA Therapy
Our team utilizes the learning principles of Applied Behavior Analysis (ABA) to develop individualized programs that target some or all of the following domains:

Cognition
Speech
Language
Executive functions
Motor skills
Adaptive skills
Academic / school readiness
Play and leisure skills
Social skills

Behaviors for reduction or elimination are also assessed, prioritized, and part of the learner’s plan. Each individualized program is based on the child’s strengths and works to decrease skill deficits. All functional behavior assessments or functional analyses require consent before the onset of the evaluation.

Applied Behavior Analysis (ABA) studies the functional relationship between one’s behaviors and environment. Data is collected on the stimuli in the person’s environment that elicit, increase, decrease, or maintain the child’s behavior. The data is analyzed, and an individualized ABA program is implemented. As the child’s treatment progresses, data is collected and analyzed frequently to determine treatment effectiveness. The goal of a behavior analyst is to utilize behavioral contingencies to help the person learn more functional skills that can replace undesirable behaviors and improve quality of life. Our team seeks to produce significant results, enabling the learner to adapt to their environment, and thus, preparing them for a brighter future.
Individualized Programming/Development
Each child is unique, and therefore, we believe it is our job to design a behavior intervention program that is individualized to your child’s specific needs.

Our Board-Certified Behavior Analysts (BCBAs) and Board-Certified assistant Behavior Analysts (BcaBAs) continually assess each learner’s needs and use evidence-based procedures founded in ABA to create a specialized program for each person.

Our highly skilled staff are trained in a wide range of ABA methodologies and techniques and engage in frequent on-going supervision.

For those enrolled in our specialized school programs, our team of educators and developmental specialists participate in the selection of learning objectives, educational activities, and other school-readiness skills.
Verbal Behavior
Verbal Behavior (VB) teaches language and communication using the principles of Applied Behavior Analysis and the theories of behaviorist B.F. Skinner. Verbal Behavior is the actions of a person that are reinforced by a listener.

It is a way of understanding the different purposes of language (e.g. a child may use language to ask for things or to label things in his environment). Each child has their method of communication – words, signs, augmentative devices, or pictures, but all people deserve to be effective communicators.

All skills are examined comprehensively to see if they are emerging evenly across all areas of language. Most traditional language approaches differentiate between receptive (listener skills) and expressive (vocal) language. Skinner’s functional analysis of verbal behavior further analyzes vocal behavior according to its function. Mand (request), tact (label) and intraverbal (talking about things in the absence of those things) are all components of “expressive language.

Focusing on the reasons we say words rather than the form of the response allows us to teach functional language skills more effectively to learners with language difficulties.

The Verbal Operants

Mand = request (you say it because you want it)

Tact = label (you say it because you see, hear, smell, taste, or feel something)

Intraverbal = conversation, answering a question, responding when someone else talks (you say it because someone else asked you a question, or commented).

Echoic = repeating what someone else says (you say it because someone else said it)
Imitation = repeating someone else’s motor movements (you move because someone else moved the same way)
Listener Responding/Receptive = following directions (you do what someone else asks you to do)

*Our goal is to help our clients understand that communicating produces positive results in their immediate environment.
Assessments - VB-MAPP, FBA, ABLLS-R, AFLS
(VB-MAPP) - The Verbal Behavior Milestones Assessment and Placement Program is a developmentally- based criterion-referenced assessment tool that was field-tested with typically developing children and children with ASD.

The VB-MAPP assesses individual skills within each repertoire area, such as the echoic, mand, tact, intraverbal, etc. It also assesses the child’s barriers to learning and contains a transition assessment which is to aid providers in making placement decisions about the level of inclusion or group instruction that may be appropriate for that learner.

There are five components of the VB-MAPP (Milestones, Barriers and Transition Assessment, Task Analysis and Skills Tracking and Placement and IEP Goals), and collectively they provide a baseline level of performance, a direction for intervention, a system for tracking skill acquisition, a tool for outcome measures and other language research projects, and a framework for curriculum planning.

Each of the skills in the VB-MAPP is not only measurable and developmentally balanced, but they are balanced across the verbal operants and other related skills.
FBA - A Functional Behavior Assessment
Is the primary tool used to identify and attempt to understand a child's behavior. It is a multidisciplinary approach that incorporates several techniques, sources of information, and strategies to understand the reasons behind problem behavior and to develop strategies or interventions to address the problem behaviors.

The process involves documenting the antecedent (what comes before the behavior), behavior, and consequence (what happens after the behavior) across time. Practitioners interview teachers, parents, and others who work with the child. Practitioners may manipulate the environment to see if a way can be found to prevent the behavior.

This information is important because it leads the observer beyond the "symptom" (the behavior) to the student’s underlying motivation to escape, "avoid," or "get" something, which is the root to all behavior. The findings from the FBA become the basis for the Behavior Intervention Plan (BIP).
ABLLS-R - The Assessment of Basic Language and Learning Skills - Revised
Is an assessment tool, curriculum guide, and skills-tracking system used to help guide the instruction of language and critical learner skills for children with autism or other developmental disabilities.

The ABLLS-R contains a task analysis of the many skills necessary to communicate successfully and to learn from everyday experiences. It provides both parents and professionals with criterion-referenced information regarding a child’s current skills and provides a curriculum that can serve as a basis for the selection of educational objectives.
AFLS - The Assessment of Functional Living Skills (AFLS)
Is an assessment, skills tracking system, & curriculum guide for the development of essential skills for achieving independence. It can be used to demonstrate a learner's current functional skill repertoire & provide tracking info for the progressive development of these skills.

The AFLS contains task analyses of the skills essential for participation in family, community, & work environments. Other assessments are completed based on the individual needs of each child.
Behavior Intervention Plans
Behavior Intervention Plans (BIPs) are developed from a Functional Behavior Assessment (FBA). BIPs increase the acquisition and use of new alternative skills, decrease the problem behavior and facilitate general improvements in the quality of life of the individual, his or her family, and members of the support team.
Social Skills Training
We provide social skills training to children with autism spectrum disorder and other developmental disabilities. The focus of the program is to increase the child’s overall ability to do the following:

Recognize and interpret verbal and non-verbal communication

Develop appropriate peer relationships
Assist individuals with improvement in social interactions by expanding their interest in age-appropriate topics, toys & play skills
Increase their ability to recognize others emotions
The goal is to minimize the stress and anxiety when participating in social interaction
The program strives to provide the tools necessary for successful interpretation of social and communication skills
Functional Communication Training
FCT is used to teach and establish replacement behaviors for inappropriate or harmful behaviors such as aggression, escape/elopement, non-compliance, and other challenging behaviors.

When a child is regularly engaging in disruptive behavior, the child is likely having difficulty communicating or meeting their wants and needs.

It is our role to develop a comprehensive ABA program to replace challenging behaviors with more effective and efficient positive/functional behaviors to get their needs and wants met in a more socially acceptable manner.
Professional Development Training (Parent/Tutor/Teacher)
Our team offers a wide range of professional development training for parents, families, and school districts in Applied Behavior Analysis.

Our workshops/training are available in full day sessions, half day sessions and evening sessions. Workshops and training can be tailored to meet your individualized needs for professional development.

Please contact us for more information.
School Consulting
Our team offers consultation for individuals in their public and private school settings and also contracts with schools who are seeking ABA services or consultation.

Community School can provide services, which address needs such as assessments, behavioral assessments, teacher and staff training, modification of curriculum, social skills facilitation, program development, and ongoing supervision.
IEP Development and Support
For learners enrolled in public school, private school, or another educational institution, our behavior analysts can provide ongoing collaboration throughout the Individualized Education Plan (IEP) process, including the construction of IEP goals and objectives, assisting in the implementation of the goals in the home and school settings, and reporting of progress.
• Each learner enrolled in Community School hasan Individualized treatment plans developed by Community School BCBA(s)/BCaBA(s) based on the historical information provided by parents/guardians, direct observation of learner skill sets (strengths & deficits) & behavioral excesses, and parent priorities.

• Community School is not required or obligated to follow IEPs or IFSPs developed by public school providers before starting at Community School.

Orientation to Services
What does treatment look like?
Treatment is viewed as a team process between the supervisors (BCBA & BCaBA), instructors (behavior technicians), family members (parents, grandparents, siblings, etc.), other caretakers / service providers (occupational therapist, physical therapist, speech/language pathologist, home-school staff, respite workers, babysitters, etc.), and others as deemed appropriate.

Feedback regarding progress is welcomed at any time. Change will often occur as a result of the hard work of the client and family members. There will often be assignments between home visits.
When can I expect home visits?
Visits are scheduled directly with the learner and/or family. Each visit generally lasts 2-4 hours. The format can be individual, family, or a combination depending on the presented issues. The number of sessions per week/day will depend upon the learner’s treatment hour recommendation.
How are appointments scheduled?
Appointments are scheduled in advance following collaborating with the family. If an appointment is canceled due to a conflict less than 24 hours before a scheduled appointment, the client or parent is responsible for contacting the supervisor or designated scheduling coordinator to inform them and reschedule.
How are missed appointments handled?
If a client or parent does not give 24 hour’s notice for canceling or missing an appointment, a fee may be charged equivalent to the allowed fees by the third-party payer.

The BCBA has the discretion to waive this fee if extenuating circumstances prevented the client from keeping the appointment. If the client canceled or missed three appointments, the need for services will be reviewed and a determination made as to whether to terminate the case.
Treatment Planning
Maladaptive behaviors and communication deficits determine the direction of ABA treatment. The BCBA, client, and family members as appropriate, select specific goals and review progress towards goals on a regular basis.

Changes or modifications to the treatment plan may be made at any time; however, changes must receive approval from the BCBA and parents prior to implementation.

BCBA-approval shall depend upon conformity to industry standards, insurance limitations, professional ethics, and the BCBA’s best judgment as to how the change(s) may support and/or fit together with the rest of the plan.

(Technicians take direction exclusively from the BCBA/BCaBA and have no authority to modify treatment plans.)
What occurs upon the completion of treatment
Treatment is completed when the client and family members, along with the BCBA, consider significant progress towards agreed upon goals has been met, and in addition, no new issues or problems have emerged.

Discharge criteria will be discussed in advance, and titration of treatment hours is common when such progress has been made.
Policy on Confidentiality
All information shared is confidential. Nothing can be released without the written release of the client or the client’s legal guardian; however, if the client is judged to be imminently suicidal or homicidal, then Louisiana state law allows for breach of confidentiality.

If child abuse or adult abuse is reported to the BCBA, then Louisiana State law mandates that the abuse be reported to the Department of Social Services. Other exceptions are outlined in the Agency Human Rights Policy.

If a parent/caretaker brings a child or adolescent in for treatment, a verbal or written agreement will be established at the start of treatment regarding what is shared with the parent/caretaker.
Mission Statement and Program Description
Holy Angel’s Mission Statement
To provide individuals with intellectual and developmental disabilities a path to self-fulfillment through education, empowerment, spirituality, independence, and work.
Program Description
We provide direct center-based, home-based, school-based, and community-based services to children, adolescents, and their families. Services are appropriate for families who have one or more children who fall on the autism spectrum or have been diagnosed with other developmental disabilities.

These services are provided without regard to race, religion, national origin, sex or cultural differences. The primary goal of this program is to preserve the family unit and improve the quality of life for the student or client and their family.

Treatment services are aimed at developing and improving the learner’s communication skills, increasing social interactions with others, and expressing and coping with emotions while developing self-regulation strategies.
This program is committed to providing effective support to families through flexible, timel,y and least intrusive services. “Least intrusive services” is defined as planning and providing services based upon ongoing family needs and using the appropriate quantity of services as required.

Our core principles inform our practices and include the following:
1. The provision of “Applied Behavior Analysis” as defined in state law and by the Behavior Analyst Certification Board (BACB).
2. Services are built around family preferences, choices, values, and individual strengths, and include the person’s family and community support system as much as possible.
3. Families are the primary decision-makers for their children and family.

4. Services are based on culture- and age-appropriateness and are aimed at maximizing interagency cooperation to maintain the youth in the family or community.

Client Rights and Responsibilities
Although these rights are written for the patient, in most cases they also apply to the patient's parents or legal guardians.

We expect staff, patients, families, and visitors to act reasonably and responsibly at all times. If you have a concern about any of these rights or responsibilities, please address your concerns first with your immediate supervisor and/or clinical supervisor to discuss concerns/solutions.

Staff and/or other individual(s) involved will be notified as needed.
Client Rights
You Have the Right
To considerate, respectful care at all times and under all circumstances, with recognition of personal dignity
To personal and informational privacy (within the law)

To verbal and written communications regarding learner progress / continued care

To verbal and written communications regarding changes to policies and procedures

To participate in the development and evaluation of the services provided to your child
…To expect that our staff is competent to obtain and interpret information in terms of your needs and to have an understanding of the range of treatment needed

To assistance with conflicts regarding services rendered

To file a complaint or grievance with the Louisiana Behavior Analyst Board or the Behavior Analyst Certification Board
To have written and electronic records kept confidential, except for disclosure as required by law

To access records about your child in accordance with applicable state and federal law, regulation, or rule
To refuse or terminate services and be informed of the consequences of reusing or terminating services
To a coordinated transfer to ensure continuity of care when there will be a change in provider
You Have the Responsibility
To be courteous to other clients and staff

To be on time for all appointments and cancel 24 hours in advance
To respect the rights of others including their confidentiality

To discuss yourself/family/children’s (as appropriate) symptoms and problems as honestly and as completely as possible (e.g., past illnesses, hospitalizations, medications, and other matters relating to your child’s health.)
To follow treatment plans recommended by the Community School clinicians

To participate fully in the parent-training component of your child’s treatment program
To ask questions about any aspect of your treatment that you do not agree with or understand
To understand all documents that you place your signature on for approval or agreement
To accept responsibility for your actions if you refuse treatment or do not follow the practitioner’s instructions
To assure that the financial obligations of your child’s health care/service are fulfilled as promptly as possible
To inform Community School of any changes in your personal situation such as, address, phone numbers, insurance information.
**Failure to notify the supervisor of insurance changes may result in abrupt discontinuation of services for insurance to make changes to the authorization of services currently in place.

Our staff is dedicated to helping children with diverse learning abilities learn skills to successfully navigate the different areas of life in all the places that life happens. Throughout the treatment process, our staff strives to protect the dignity and welfare of all who receive services from us.
Our Ethical Obligations
1. Serving the best interest of each client 2. Not discriminate between clients or professionals based on age, race, creed, disabilities, handicaps, preferences, or other personal concerns 3. Maintain an objective and professional relationship with each client 4. Respect the rights and views of other mental health professionals 5. Appropriately end services or refer clients to other programs when appropriate 6. Evaluate our personal limitations, strengths, biases, and effectiveness on an ongoing basis for self-improvement
7. Continually attain further education and training 8. Respect various institutional and managerial policies but help to improve such policies if the best interest of the client is served

What to do if you believe your rights have been violated:
If you believe that your client's rights have been violated, contact our Program Director immediately for resolution.

How to Get Help During an Emergency
If this is a medical emergency, dial 911, and follow the operator’s instructions.
For access to Poison Control, call 1(800) 222-1222

If you would like to contact your BCBA for an emergency, please call the Community School phone immediately: (318) 780-4419
Consent for Treatment and Recipient’s Rights
Client Name *

First NameLast Name
DOB*

MonthDayYear
Date
I blanks the undersigned, hereby attest that I have voluntarily entered into treatment, or give my consent for the minor or person under my legal guardianship mentioned above, hereby referred to as Community School, . Further, I consent to have treatment provided by the BCBA, BCaBA, and the Technician(s) on the case. The rights, risks, and benefits associated with the treatment have been explained to me. I understand that the therapy may be discontinued at any time by either party. The clinic encourages that this decision be discussed with the treating BCBA. This will help facilitate a more appropriate plan for discharge.

Recipient’s Rights: I certify that I have received information concerning Recipient’s Rights and certify that I have read and understand its content. I understand that as a recipient of services, I may get more information from the Recipient’s Rights Advisor. Unless otherwise notified, I understand that my Recipient’s Rights Advisor is the BCBA overseeing my case.

Non-voluntary Discharge from Treatment: A client (i.e., “client” refers to the client and their family) may be terminated non voluntarily if: (A) the client exhibits physical violence, verbal abuse, carries weapons, or engages in illegal acts; and/or (B) the client refuses to comply with stipulated program rules or refuses to comply with treatment recommendations. The client will be notified of a non-voluntary discharge by letter. The client may appeal this decision with the Clinical Director or request to reapply for services at a later date.

Client Notice of Confidentiality: The confidentiality of client records maintained is protected by federal and/or state law and regulations. Generally, we may not say to a person outside of Community School that a client attends the program or disclose any information identifying a client unless: (1) the client consents in writing, (2) the disclosure is allowed by a court order, or (3) the disclosure is made to medical personnel in a medical emergency, or to qualified personnel for research, audit, or program evaluation/implementation.

Violation of federal and/or state law and regulations by a treatment facility or provider is a crime. Suspected violations may be reported to appropriate authorities. Federal and/or state law and regulations do not protect any information about a crime committed by a client either at Community School, against any person who works for the program, or about any threat to commit such a crime. Federal law and regulations do not protect any information about suspected child (or vulnerable adult) abuse or neglect, or adult abuse from being reported under federal and/or state law to appropriate state or local authorities. Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. It is Community School’ duty to warn any potential victim when a significant threat of harm has been made. In the event of a client’s death, the spouse or parents of a deceased client have a right to access their child’s or spouse’s records. Client/Legal Guardian’s Initials Signature
blank

Professional misconduct by a healthcare professional must be reported by other health care professionals, in which case related client records may be released to substantiate disciplinary concerns. Parents or legal guardians of non-emancipated minor clients have the right to access the client’s records. When fees are not paid in a timely manner, a collection agency will be given appropriate billing and financial information about the client, but not clinical information. My signature below indicates that I have been given a copy of my rights regarding confidentiality. I permit a copy of this authorization to be used in place of the original. Client data of clinical outcomes may be used for program evaluation/coordination and child advocacy purposes, but individual results will not be disclosed to outside persons not related to the child’s care. I consent to treatment and agree to abide by the above-stated policies and agreements with Community School.
Signature of Parent/Guardian*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Participating Staff Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date

AUTHORIZATION TO BILL INSURANCE
Client Name

First NameLast Name
DOB

MonthDayYear
Date
I blanks* hereby give my consent for Community School, to bill my/my child’s insurance carrier for the services rendered to my child by the above- mentioned provider. In addition, I agree to pay Community School, any deductible or uncovered charge in accordance with my health care plan.

Signature of Parent/Guardian *
blank*

Date*

Participating Staff Signature

Date

Human Rights Notification
Each individual who receives services shall be assured protection to exercise his/her legal, civil and human rights related to the receipt of services, shall be shown respect for his/her basic dignity, and shall be provided services consistent with sound therapeutic practices.

Every client receiving services will be treated with dignity and be protected, respected, and supported in exercising all of his/her legal, civil and human rights. All staff are prohibited from limiting or taking away these rights for any reason, including a client’s disabilities or barriers that may be created due to a disability.

It is your right… … to be treated with dignity and respect … to be asked questions and be told about your treatment … to have a say in your treatment … to speak to others in private … to have complaints resolved … to say what you prefer … to ask questions and be told about your rights … to get help with your rights

Upon request, you will be given a complete copy of the Human Rights Plan and/or a copy of the Louisiana State Human Rights Regulations.

blanks (Initial)
No, I would NOT like to request a complete copy of the Human Rights Plan or the Louisiana State Human Rights regulations.

blank (Initial) Yes, I would like to request a complete copy of the Human Rights Plan and the Louisiana State Human Rights regulations.

Date of copy given to client/parents   Date

Clients must be notified in writing annually of his/her human rights.
Signature of Parent/Guardian:
Signature
Date

Signature of Client (if applicable)
Signature
Date

Participating Staff Signature
Signature
Date

Client Grievance Procedures
When a client or parent has a grievance with a behavior technician, they should address the matter directly with the technician’s supervisor (BCBA). If the matter is not resolved within a reasonable period, the client or parent should address the issue a second time with the technician’s supervisor.

If the concern remains unsettled, then the client or parent should make an appeal to the Program Director. The Program Director shall have the power to make final determinations on all clinical decisions related to services provided by Community School, that fall under her oversight.

If the complaint involves a problem that goes beyond clinical care or involves the Program Director herself, then the client or parent may request to be referred and transitioned to another practicing licensed behavior analyst for services.

When a client has a grievance with an administrative staff, they will be directed to address the grievance with their BCBA first. If the grievance cannot be resolved with the BCBA, the Program Director will be called upon to address the grievance. The Director has authority to make final administrative decisions on behalf of Community School.

Anytime there is a grievance made about an administrative staff, technician, or BCBA, that person will be informed of the grievance and be given an opportunity to participate in the resolution of the grievance as appropriate. All parties agree to act in good faith to resolve grievances in the simplest and most respectful manner possible. A client or parent always has the right to discontinue services at any time.

Notice of Privacy Practices
Confidentiality
The behavior technician, RLT or RBT, will be supervised as required by the Louisiana Behavior Analyst Board (LBAB) and the Behavior Analyst Certification Board (BACB). Treatment details may be discussed with other professionals related to the case. If this consultation involves multiple staff members, they will each endeavor to avoid revealing the identity of their clients.

The consultant is also legally bound to keep the information confidential. Your BCBA may discuss and show your chart to their Clinical Supervisor and to other staff directly involved with your case for the purpose of case consultation and direct care.

In general, the law protects the privacy of all communication between a client and a BCBA, and your BCBA can release information about your work to others only with your written permission.

There are exceptions. If child abuse or adult abuse is suspected by or reported to the BCBA, then Louisiana State law mandates that the abuse be reported to the Department of Social Services, even if they must reveal some information about a client’s treatment.

In general, the law protects the privacy of all communication between a client and a BCBA, and your BCBA can release information about your work to others only with your written permission. There are exceptions. If child abuse or adult abuse is suspected by or reported to the BCBA, then Louisiana State law mandates that the abuse be reported to the Department of Social Services, even if they must reveal some information about a client’s treatment.

If a client is threatening serious bodily harm to another, it is the duty of staff to warn any potential victim that a significant threat of harm has been made and take any other needed actions. These actions may include contacting the police or seeking hospitalization for the client. If the client threatens to harm himself/herself, the BCBA may be obligated to seek hospitalization for him or her or to contact family members or others who can help provide protection. Every effort to fully discuss these issues with you before taking any action.

In most legal proceedings, you have the right to prevent your BCBA from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order your BCBA’s testimony if he or she determines that the issues demand it.

Functions are provided to benefit the operation of your BCBA and your case management. There are functions that require the sharing of your health information to effectively administer, bill, and seek payment for services received.
Information Disclosure Authorizations Certain disclosures are necessary to other parties who may be related to your case. By signing below, you state you have read and understand these policies, and you hereby authorize appropriate disclosures to the following persons/agencies if applicable:
- Your physician and/or other healthcare-related professional
- Public school personnel in relation to child advocacy services provided by Community School
- Caseworker/case manager as appropriate for coordination of services and/or
- Medicaid and/or other applicable insurance providers as required.
Signature of Parent/Guardian
Signature
Date

Signature of Client (if applicable):
Signature
Date

Participating Staff Signature
Signature
Date

How to Contact your Service Providers
ABA services will be provided Monday through Friday from 8:00 am to 5:00 pm weekly.

Emergency services will be available 24 hours a day, seven days a week.

For routine communication (scheduling changes, canceling appointments, etc.), contact the Community School cell phone and leave a message.
Office Manager
Amber Upchurch
Community School Cell Phone: (318) 780-4419

* For communication regarding clinical concerns and updates (medication updates, concerning changes in learner behavior in other settings, etc.), contact one of your clinical supervisors (*see contact info below).

For questions and concerns that require any back-and-forth discussion, caregiver training meetings may need to be scheduled ---these meetings can be conducted in-person (on-campus; client-home) or via Zoom.

Clinical Supervising Staff

CS Director: Kelly Rouse, BCBA, LBA
Email: krouse@laholyangels.org

Supervisor: Elizabeth Murray, BCaBA, SCABA
Email: emurray@laholyangels.org

Supervisor: Nicki Abrams-Bracey, BCBA, LBA Email: lbracey@laholyangels.org

Their Emergency Contact Number is: (318) 780-4419

blanks
Contacting Your Service Provider While they are usually available, they will not answer the phone if they are with a client.

When they are unavailable, please leave a message on their voicemail or by text. They will make every effort to return your call on the same day you make it.

If you are difficult to reach, please inform them of some times when you will be available.

If you are unable to reach them and feel that you cannot wait for them to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call.

If your service provider is unavailable for an extended time, they will provide you with the name of a colleague to contact, if necessary, and that information will be on their voicemail.

Email is not a secure, confidential form of communication and should therefore not be used for communication-related to private information.

Privacy of Information Policies
This form describes the confidentiality of your medical records, how the information is used, your rights, and how you may obtain this information.
Our Legal Duties
State and federal laws require that we keep your medical records private. Such laws require that we provide you with this notice informing you of our privacy of information policies, your rights, and our duties.

We are required to abide by these policies until replaced or revised. We have the right to revise our privacy policies for all medical records, including records kept before policy changes were made. Any policy changes will be made available in writing, upon request, prior to their effective date.

The contents of material disclosed to us in an evaluation, intake, or counseling session are covered by the law as private information. We respect the privacy of the information you provide us and we abide by ethical and legal requirements of confidentiality and privacy of records.
Use of Information
Information about you may be used by the personnel associated with Community School, for diagnosis, treatment planning, treatment, advocacy, and continuity of care.

We may disclose it to healthcare providers who provide you with treatment, such as doctors, nurses, mental health professionals, and mental health students and mental health professionals, or to business associates affiliated with ABA such as billing, quality enhancement, training, audits, and accreditation.

Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian or personal representative.

It is the policy of this practice not to release any information about a client without a signed release of information except in certain emergency situations or exceptions in which client information can be disclosed to others without written consent. Some of these situations are noted below, and there may be other provisions provided by legal requirements.
Duty to Warn and Protect
When a client discloses intentions or a plan to harm another person or persons, the healthcare professional is required to warn the intended victim and report this information to legal authorities.

In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.
Public Safety
Health records may be released for the public interest and safety for public health activities, judicial and administrative proceedings, law enforcement purposes, serious threats to public safety, essential government functions, military, and when complying with worker’s compensation laws.
Abuse
If a client states or suggests that he or she is abusing a child or vulnerable adult, or has recently abused a child or vulnerable adult, or a child (or vulnerable adult) is in danger of abuse, the healthcare professional is required to report this information to the appropriate social service and/or legal authorities.

If a client is the victim of abuse, neglect, violence, or a crime victim, and their safety appears to be at risk, we may share this information with law enforcement officials to help prevent future occurrences and capture the perpetrator.
Prenatal Exposure to Controlled Substances
Healthcare professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.
In the Event of a Client’s Death
In the event of a client’s death, the spouse or parents of a deceased client have a right to access their child’s or spouse’s records.
Professional Misconduct
Professional misconduct by a healthcare professional must be reported by other health care professionals. In cases in which a professional or legal disciplinary meeting is being held regarding the health care professional’s actions, related records may be released in order to substantiate disciplinary concerns.
Judicial or Administrative Proceedings
Health care professionals are required to release records of clients when a court order has been issued.
Other Provisions
When payment for services is the responsibility of the client, or when a person who has agreed to provide payment, has not made payment in a timely manner, collection agencies may be utilized in collecting unpaid debts. In such a case, the specific content of the services (e.g., diagnoses, treatment plans, progress notes, testing) is not disclosed. If a debt remains unpaid, it may be reported to credit agencies, and the client’s credit report may state the amount owed, the time frame, and the name of the clinic or collection source.

Insurance companies, managed care, and other third-party payers are given information that they request regarding services to the client. Information which may be requested includes type of services, dates/times of services, diagnoses, treatment plans, description of impairment, progress of therapy, and summaries.

Information about clients may be disclosed in consultations with other professionals to provide the best possible treatment. In such cases the name of the client, or any identifying information, is not disclosed. Clinical information about the client is discussed. Some progress notes and reports are dictated/typed within the clinic or by outside sources specializing in (and held accountable for) such procedures.

In the event in which the healthcare professional must telephone the client for purposes such as appointment cancellations or reminders, or to give/receive other information, efforts are made to preserve confidentiality.

Please notify us in writing where we may reach you by phone and how you would like us to identify ourselves. For example, you might request that when we phone you at home or work, we do not say the name of the practice or the nature of the call, but rather the healthcare professional’s first name only.

If this information is not provided to us, we will adhere to the following procedure when making phone calls: First we will ask to speak to the client (or guardian) without identifying the name of the clinic. If the person answering the phone asks for more identifying information, we will say that it is a personal call. We will not identify the clinic (to protect confidentiality). If we reach an answering machine or voicemail, we will follow the same guidelines.
Special Education Advocacy
In the event we provide special education advocacy services, most references to the client’s medical condition will be contained within the record available to the appropriate school personnel and IEP team, and therefore will not require additional disclosure.

However, there may be incidental references to pertinent information not contained within the record, particularly when relaying observations made by Community School’s personnel which might be strategically important to address on the client’s behalf.

Our staff is authorized to communicate with school personnel within the scope of advocacy services on behalf of the client and guardian. Community School’s staff shall promptly make known to the client/guardian the substance of such communications.
Your Rights
You have the right to request to review or receive your medical files. The procedures for obtaining a copy of your medical information are as follows: You may request a copy of your records in writing with an original (not photocopied) signature.

If your request is denied, you will receive a written explanation of the denial. Records for non-emancipated minors must be requested by their custodial parents or legal guardians.
You have the right to cancel a release of information by providing a written notice. If you want your information sent to a location different from our address on file, you must provide this information in writing.

You have the right to restrict which information might be disclosed to others. However, if we do not agree with these restrictions, we are not bound to abide by them.

You have the right to request that information about you be communicated by other means or to another location. This request must be made to us in writing.

You have the right to disagree with the medical records in our files. You may request that this information be changed. Although we might deny changing the record, you have the right to make a statement of disagreement, which will be placed in your file.

You have the right to know what information in your record has been provided to whom. Request this in writing.

If you desire a written copy of this notice, you may obtain it by requesting it from the Program Director.

I understand the limits of confidentiality, privacy policies, my rights, and their meanings and ramifications.

Signature of Parent/Guardian
Signature
Date

Signature of client (if applicable):
Signature
Date

Participating Staff Signature
Signature
Date

CONFIDENTIALITY ACT - ABUSE-REPORTING PROTOCOL
Client Name *

First NameLast Name
DOB*

MonthDayYear
Date
Parent/Guardian Name *

First NameLast Name
I understand all information related to the above-named client's assessment and treatment must be handled with strict confidentiality. No information related to the client, either verbal or written, will be released to other agencies or individuals without the express written consent of the client's legal guardian. By law, the rules of confidentiality do not hold under the following conditions:

1. If abuse or neglect of a minor, disabled, or elderly person is reported or suspected, the professional involved is required to report it to the Department of Children and Families for investigation.

2. If, during the course of services, the professional involved receives information that someone's life is in danger, that professional has a duty to warn the potential victim.

3. If our records, our subcontractor records or staff testimony are subpoenaed by court order, we are required to produce requested information or appear in court to answer questions regarding the client.

Signature of Parent/Guardian
Signature
Date

Signature of Client (if applicable)
Signature
Date

Participating Staff Signature
Signature
Date

FREEDOM OF CHOICE OF PROVIDER
I understand I have a choice of providers for receiving ABA center-based, home-based, school-based, or community-based services. I have been made aware that I have a choice of other providers offering this service, and I have chosen Community School as my service provider.

RIGHT TO APPEAL

I also understand that I have the right to appeal if I have any concerns about decisions that affect my receiving this service. Upon request, Community School will supply me with all the information necessary to access my right to a fair hearing.

Signature of Parent/Guardian
Signature
Date

Signature of Client (if applicable)
Signature
Date

Participating Staff Signature
Signature
Date

Functional Behavioral Assessment (FBA) Consent Form
As a way to best serve your child, name we would like to conduct a Functional Behavioral Assessment (FBA). A Functional Behavioral Assessment is the process of:
- Identifying problematic behavior(s)
- Identifying environmental events which impact problematic behavior(s)
- Determining the cause/function of the problematic behavior(s)
- Outlining strategies/interventions that may be effective based on data collected during the FBA process
An FBA may include, but is not limited to, the components:
- REVIEW OF RECORDS: Including medical records; progress notes / evaluations from other therapy service providers (OT, PT, SLP, etc.); history of problematic behavior(s) and previous interventions (time implemented; effectiveness; etc.)
- INTERVIEWS / RATING SCALES: Completed by the learner (if applicable), parent(s) / guardian(s), caretaker(s), teacher(s) regarding the learner’s behavior
- DIRECT OBSERVATION: Conducted across settings/situations in which learner does / does not engage in problematic behavior(s)
- DATA COLLECTION: Objectively define problematic behaviors, what happens right BEFORE problematic behavior(s) occur (Antecedents), and what happens right AFTER problematic behavior(s) occur (Consequences) and measure current levels of problematic behavior(s) (e.g., frequency; rate; duration; etc.)
We greatly appreciate your involvement during each step of the process. The assessments will be shared with you upon completion. Please sign below to indicate whether or not you give consent for Community School to conduct a Functional Behavior Assessment (FBA) for problematic behavior(s) identified below and to also continue to collect information throughout the 6-month authorization period for tracking, updating and modifying purposes. Please initial next to each problematic behavior listed. A new FBA Consent Form will be completed for any new problematic behaviors that arise not listed on the current consent authorization form.

I DO give consent for my child,     First Name   Last Name  to participate in a Functional Behavioral Assessment for the problematic behavior(s) initialed below.

I DO NOT give consent for my child, to participate in a Functional Behavioral Assessment for the problematic behavior(s) initialed below.   First Name   Last Name

Initial   (Behavior 1)   Type a label
Initial   (Behavior 1)   Type a label
Initial    (Behavior 1)   Type a label
Initial   (Behavior 1)   Type a label

Signature of Parent/Guardian
Signature
Date

Signature of Client (if applicable)
Signature
Date

Participating Staff Signature
Signature
Date

Transportation Authorization
By signing this form, I am permitting the staff who have undergone Holy Angels Safe Driver Training on my child’s team to transport my child,   First Name   Last Name  , if needed. Any time transportation is to take place, the parent/legal guardian will be notified and permission granted before transportation taking place. Transportation will occur in a Holy Angel’s vehicle and only occur to and from mutually agreed upon destinations.

Signature of Parent/Guardian
Signature
Date

Signature of Client (if applicable):
Signature
Date

Participating Staff Signature
Signature
Date
Permission to Photograph/Videotape/Audiotape
Client's name

First NameLast Name
DOB

MonthDayYear
Date
Type a question

I give permission and consent for Community School to photograph 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 and/or document progress. I understand that this is a voluntary agreement and will not affect my child’s therapy program and can be changed at any time.In addition to the above, I also give permission for Community School to use full-face photographs of my child for promotional or marketing materials.I give permission and consent for Community School 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 Community School.I give permission and consent for Community School to videotape and/or photograph my child and/or myself during the time my child is enrolled in services for the purposes of sharing effective permanent product through the use of the Brightwheels app and also for the purpose of education and training for Community School (birth-7 years).I do not give permission for Community School to take photographs of my child. I understand that this is a voluntary agreement and will not affect my child’s therapy program and can be changed at any time.
Signature of Parent/Guardian

Powered by Jotform SignClear
Date

MonthDayYear
Date
Signature of Client (if applicable)

Powered by Jotform SignClear
Date

MonthDayYear
Date
Participating Staff Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date

Consent for Participation in Swim Program
Client's Name

First NameLast Name
DOB

MonthDayYear
Date
Children enrolled in Community Schools will be scheduled for classroom group swim instruction as part of their physical education throughout the year.

WHEN
Swim classes will occur 2-3 times per week

WHERE:
Swim classes will occur in the indoor pool -- the outdoor pool will be utilized during the summer as weather and scheduling permit.

WHO:
Swim classes will consist of the same peers from the regular classroom

Classes will be conducted by a minimum of 2 staff members:
- Lead instructor (in water) – focus on water safety & swim instruction
- Assistant (on deck) – focus on behavior (i.e., implement BIPs-- antecedent modifications & consequence procedures).

WHAT:
Swim program areas of focus include….daily physical activity; compliance; following instructions; safe/age-appropriate leisure activities in water; stroke/motor skill development; communication/language

HOW:
Class swim programs will be…individualized to the needs & skill level of class; conducted using strategies based on the principles of behavior; developed & overseen by supervising BCBA/BCaBA

Please check your preference in the box

I give my child permission to participate in swim classes at Community School.    I DO NOT give my child permission to participate in swim classes at Community School.

Signature of Parent/Guardian
Signature
Date

Signature of Client (if applicable)
Signature
Date

Participating Staff Signature
Signature
Date

TELEHEALTH PRACTICES & PROTOCOLS
During COVID19, the use of Telehealth services continues to be critical to the management of patient care, preventing interruptions in treatment delivery when possible. Telehealth services may include the following, as it is deemed relevant to a patient’s treatment plan

1. Real-time, videoconferencing visits
2. Parent training, education, or collaboration
3. Delivery of therapeutic services by a trained Registered Line Tech (RLT), Board-Certified assistant Behavior Analyst (BCaBA), or Board-Certified Behavior Analyst (BCBA) as deemed appropriate
4. Remote patient monitoring procedures for those in rural areas lacking direct care services

The goal of telehealth is not to replace direct care of patients, but instead increase the overall health and generate positive impact for patients during the pandemic. While Telehealth services remain in place at this time due to concerns around COVID19, direct care of patients is predominantly the method of service delivery. In cases of patient restrictions due to illness, disease, disorder, or high-risk for exposure to COVID19, telehealth is available to patients and their families at this time. Parent training and supervision may also occur via Telehealth in cases where direct supervision is not possible due to distance of travel or other unforeseen circumstances.

Purpose
To define the responsibilities of the coordinator to permanent and temporary staff who assume responsibilities for the services if the coordinator is not able to perform his/her duties. The Community School has a commitment to efficient coordination of patient referrals. In order to do so, we have established simple processes to create a more standardized methodology for our practice.

Setting of Services
Community School
10450 Ellerbe Road
Shreveport, LA 71106

Telehealth Procedures
Each client will sign a Consent for Telehealth Services at onset of clinical relationship as applicable prior to receiving telehealth services. Prior to the session, the clinician should conduct the following

1. Restart his/her computer and close all background programs.
2. Test internet connection speed. Speeds of 10 mpbs will provide the best experience.
3. Confirm the webcam, microphone and speakers are working. Audio should not be muted.
4. Set the cell phone to silent and secure location of session. Hang a “In Session” sign when possible.

Instructions for the clinician
1. Log into your computer using your own log in and password.
2. Log into your secure account.
3. Click on the relevant appointment, marked as “Telehealth: Video Office” as the location.
4. Click “Start Video Session” to launch Telehealth in a new tab of the browser.
5. Enter your name to join.
6. Verify client’s identity if needed. Document full name of those present.
7. Confirm client is in safe, private place for session.
8. Review back up plan in case connection fails. Confirm phone number on file.
9. Inform the client of potential risks and limitations of Telehealth.
10. Review the protocol for Telehealth visit and explain what to expect.

Instructions for the client
1. The client will automatically receive and email or text reminder for Telehealth appointment approximately 10 minutes prior to their start time.
2. The text reminder cues client to check their email, as the email includes the unique link to join the video call.
3. When the client clicks on the link, a new tab will open in their browser.
4. The client enters their name to join. If the appointment goes longer than 30 minutes past the scheduled appointment end time, the call will be disconnected by the video

If the appointment goes longer than 30 minutes past the scheduled appointment end time, the call will be disconnected by the video platform. Telehealth works on the latest versions of Google Chrome and Mozilla Firefox on desktops / laptops.

Documentation

Documentation of the session should be thorough and complete at the time of the session. Protocols regarding completing session notes are followed.

CONSENT TO TELEHEALTH SERVICES

1. I understand that my health care provider wishes me to engage in a telehealth session to receive behavioral health services appropriate for my treatment plan.

2. My healthcare provider explained to me how the video conferencing technology that will be used to affect such a session will not be the same as a direct client/healthcare provider visit due to the fact that I will not be in the same room as my provider.

3. I understand that a Telehealth session has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

4. I understand that there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my healthcare provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

5. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this protocol. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

CONSENT TO USE THE TELEHEALTH BY ZOOM SERVICE

Telehealth by ZOOM is the technology service we will use to conduct telehealth video conferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge

1. Telehealth by Zoom is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.

2. Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither Simple Practice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.

3. The Telehealth by Zoom Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.

4. I do not assume that my provider has access to any or all of the technical information in the Telehealth by Zoom Service – or that such information is current, accurate or up to date. I will not rely on my health care provider to have any of this information in the Telehealth by Zoom Service.

5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

By signing this form, I certify:
- That I have read or had this form read and/or had this form explained to me.
- That I fully understand its contents including the risks and benefits of the procedure(s).
- That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
BY SIGNING THIS FORM, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT

Signature of Parent/Guardian
Signature
Date

Signature of Client (if applicable)
Signature
Date

Participating Staff Signature
Signature
Date

CERTIFICATION & LICENSURE BOARD INFORMATION
Licensed Behavior Analysts (LBAs) and State Certified Assistant Behavior Analysts (SCABAs) are licensed and certified by the Louisiana Behavior Analyst Board (LBAB). Registered Line Technicians (RLTs) and SCABAs practice under the direct supervision of the LBA. More information can be found at www.lababoard.org. Complaints can be made on this website.

To become licensed on the state level, behavior analysts must first be nationally certified by the Behavior Analyst Certification Board (BACB). Board Certified Behavior Analysts (BCBAs) and Board Certified Assistant Behavior Analysts (BCaBAs) are nationally certified by the BACB. More information can be found at www.bacb.com. Complaints can be made here as well. All certifications and licenses can be made available for review upon request.
Informed Consent for Restrictive Procedures
This document is to inform parents that in very rare circumstances, a client may need to be physically restrained due to serious risk of harm to self and others. During these situations, staff members who are certified to use Crisis Preventions Institutes (CPI) Nonviolent Intervention will be called in to assist in de-escalating, and as a last resort, intervene to restrain the client or transport the client to a safe environment or both. This training is to minimize the risk of physical harm.

a. Definition of self-harm - if a client is placing herself or himself in a situation where she or he may get seriously hurt, trained staff will act to prevent a child from harming self.
Situations where the client may place self in harm's way may include but is not limited to running from the building, or into rooms where there are dangerous items with which the client might use to climb dangerous heights, objects that can be used for significant self-injury behaviors, etc. A client may also be deemed at risk of harming his or herself if engaging in self-injurious behaviors such as excessive head banging, biting self, scratching self, excessive hair pulling, etc.

b. Definition of harm to others - if a client attempts to harm others including staff or clients, trained staff will act to prevent the child from harming others. Situations where client may place others in harm's way may include but is not limited to: hiking, biting, using objects to harm others, or is threatening others and has a history of following through on such threats, etc.

c. If a client is destroying property, verbal and non-verbal techniques will be the first choice to respond. The only time Nonviolent Physical Crisis Intervention would be used is when the destruction of that property places the client at risk of self-harm and using the destroyed items to harm someone else. For example, if a client is attempting to break glass, this would be a time to intervene as serious injury may result from broken glass.

d. If a child runs away or bolts usual ABA approaches using physical prompts to return the child to the expected area will be used. If, however, the client is at risk of being harmed by traffic or other situations, the Nonviolent Physical Crisis Intervention would be implemented to reduce the risk of harm.

Parents will be informed if this intervention has been required. If a pattern begins to emerge of a child needing physical restraints, a meeting will be held with parents to review treatment plan and interventions to determine the best way to interrupt this pattern.

BY SIGNING THIS FORM, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

Signature of Parent/Guardian:   Signature
Date

Signature if Client (if applicable):   Signature
Date

Participating Staff Signature:   Signature
Date
Health Insurance Portability and Accountability Act Privacy Notice (HIPAA)
This notice describes how Community School uses and discloses your medical and other identifying Protected Health Information (PHI). In addition, this notice describes your legal rights regarding your records and the process for accessing your records. Please review this notice carefully. You will be asked to sign the Authorization for Treatment Form, later in this packet, to document your receipt of this information and formal agreement of these practices.

As part of providing services, Community School will collect PHI about your child’s health care and your family. Community School needs this PHI to provide quality services and to comply with certain legal requirements. This notice applies to all records generated by the Community School. This law requires us to:
- Make sure that records with identifying PHI are kept private
- Give you this notice of our legal duties and privacy practices with respect to PHI
- Follow the terms of the Privacy Notice that is currently in effect
How Community School May Use and Disclose PHI

Listed below are a number of reasons or ways in which Community School may disclose PHI. In each category, there is an explanation of the reason and usually an example. This notice does NOT LIST EVERY USE OR DISCLOSURE IN A CATEGORY. The reasons Community School might disclose PHI includes:

➢ For Treatment: Community School may disclose PHI to Community School personnel or outside of Community School to others who are involved in providing care to you or your child. For example, Community School Senior Therapists meet weekly to discuss challenging behaviors and programming and may share PHI at that time. In addition, with written consent, Community School may communicate with your child’s Parish Case Manager.

➢ For Payment: Community School may use and disclose PHI so that services may be billed, and payment may be collected from an insurance company or a government health program. Community School may also tell your health plan about a service your child may receive to obtain prior approval or to determine whether your health plan will cover the treatment. As legal guardians, you must provide informed consent for Community School to release this PHI.

➢ For Health Care Operations: Community School may use Community School to run our program and to make sure Community School is providing quality services or to decide if services should be changed or modified.

➢ As Required by Law: Community School will disclose PHI when required by federal, state, or local law. For example, state law requires Community School to report suspected abuse or neglect to the proper authorities, which will require the release of PHI. This use of PHI does not require consent

➢ To Avoid a Serious Threat to Health or Safety: Community School may use or disclose PHI when necessary to prevent a serious threat to your child’s health and safety or the health and safety of the public or another person. As legal guardians, you will have the opportunity to provide written consent for this use of PHI.

➢ Military and Veterans: If you are a member of the armed forces, Community School may release PHI about you as required by military command authorities without additional consent.

➢ Workers’ Compensation: Community School may release PHI for workers’ compensation or similar programs when required by law to do so. For example, if you are involved in a claim for workers’ compensation benefits, Community School may release PHI requested about your child’s health.

➢ Health Oversight Activities: Community School may disclose PHI to a health oversight agency for activities authorized by law. Examples are government audits, investigations, inspections, and licensure.

➢ Lawsuits and Disputes: If you are involved in a lawsuit or dispute, or if there is a lawsuit or dispute concerning our services or someone who provided services to you, Community School may disclose PHI in response to a court or administrative order. 45 Community School may also disclose PHI in response to a subpoena, discovery request, or other lawful process from someone else involved in the dispute, but only if efforts have been made to inform you about the request prior to providing the PHI to allow you to obtain an order protecting the PHI requested.

➢ Law Enforcement: In certain situations, Community School may release PHI to law enforcement officials. For example, Community School might release PHI about you to identify or locate a missing person; about a death at Community School that may be the result of criminal conduct; or in emergency circumstances to report a crime, the location of the crime or victims, or the identity, description of location of the person believed to have committed the crime.

➢ Coroners, Medical Examiners and Funeral Directors: Community School may release PHI to a coroner or medical examiner to identify a deceased person or determinate a cause of death. Community School may release PHI to funeral directors as necessary to help them carry out their duties.

➢ National Security and Intelligence, Protective Services for the President, and Others: Community School may release PHI to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.

➢ Correctional Programs: If you are an inmate or in the custody of a law enforcement officer, Community School may release PHI to the correctional institution or law enforcement official, to protect your health and safety or the health and safety of others.

Your Rights and Your Child’s Rights Regarding Your Protected Health Information

As legal guardians for your child, you have the following rights:

To Inspect and Copy Community School Service Records: Usually this includes medical and billing records but may exclude psychotherapy notes. To inspect and copy PHI in your record you must submit a request in writing to the Chief Executive Officer or HIPAA Compliance Officer. Community School is allowed to charge a reasonable fee for the costs of copying, mailing or other costs related to your request.

In very limited circumstances Community School may deny your request. If Community School denies your request, you may ask that the denial be reviewed. Another licensed health care professional of Community School will then review your request and either uphold the original decision or reverse it.

To Amend Your Record. If you believe that the PHI Community School has about you and/or your child is incorrect or incomplete; you may make a written request to the HIPAA Compliance Officer to amend the PHI. You must include a reason that supports your request.

Community School may deny the request if it is not in writing or does not include reasons to support the request.

Community School may also deny your request if you ask us to amend PHI that:
- was not created by us, unless the person/entity that created the PHI is no longer available to make the amendment
- is not part of the PHI kept in our file
- Is not part of the PHI you would be permitted to inspect and copy
- Community School believes the PHI is accurate and complete
If you disagree with the denial, you may submit a statement of disagreement. If you request an amendment to your record, Community School will include your request in the record, whether the amendment is accepted or not.

To Receive an Accounting of Disclosures: Community School will keep a log of disclosures made on or after September 01, 2022, other than disclosures for treatment, billing, or health care operations. You have the right to request the list of disclosures. You must submit a written request to the HIPAA Compliance Officer. The request may not cover more than a six-year period.

To Request Restrictions: You may request a restriction on the disclosure of PHI for treatment, payment, or health care operations. Your request must be in writing to the HIPAA Compliance Officer. Your request must clearly state

1) what PHI is to be limited
2) whether you want to limit our use, our disclosure or both; and
3) to whom you want the limit to apply. For example, you could ask that Community School not use or disclose PHI to a certain person about services your child has received.

Community School does not have to agree to your request to restrict access to PHI.

If Community School does agree, Community School will comply with your request unless the PHI is needed to provide emergency treatment or to comply with a lawful and legal request or investigation.

To Request Alternative Ways to Communicate: You may request that Community School communicate with you about services in a certain way or at a certain location. For example, you can ask that Community School contact you only at work, or only by mail. Your request must be in writing, must tell us how you would like us to communicate with you, and must be sent to the HIPAA Compliance Officer. Community School will accommodate all reasonable requests.

To Receive a Paper Copy or Electronic Copy of this Notice: You have the right to receive a paper or an electronic copy of this notice from the HIPAA Compliance Officer.

Additional Rights Under State Law: State privacy laws may provide additional privacy protections. Any such protections will be attached in a separate State addendum to this Notice.

Changes to this Notice: Community School may change this notice in the future. Community School can make the revised or changed notice effect for PHI Community School already have about you as well as any PHI Community School may create or receive in the future.

Complaints: If you believe your privacy rights have been violated, you may file a complaint with the HIPAA Compliance Officer or with the Secretary of Health and Human Services. All complaints must be in writing. Community School will not retaliate against you for filing a complaint.

BY SIGNING THIS FORM, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

Signature of Parent/Guardian   Signature
blanksblank
Date

Signature of Client (if applicable)   Signature
Date

Participating Staff Signature   Signature
Date

Financial Agreement
This financial agreement sets Community School's expectations regarding payment. Financial arrangements shall be discussed and understood prior to the onset of services and before any problems or concerns develop.

Prior to service initiation, Community School will work with you to ensure that the funding source you are planning to use will pay for services. It is the parents’ responsibility to monitor the funding source they are utilizing and to immediately notify Community School of any changes to insurance or other coverages.

When discussing payment for services with insurance companies, it is important that the insurance company clearly understands the type of services Community School provides. Community School provides both focused and comprehensive behavioral therapy across center, community, home, and school-based programs, as deemed appropriate. Some learners may receive additional and/or other non-ABA services during their day at Community School and Center. These services are separate and funded by different sources and are not billed or submitted to payers as ABA services.

It is essential that Community School is involved in the prior authorization process. It is necessary for you to provide our intake and billing staff with the required information that enables us to bill your insurance company. In some circumstances, even participating insurance plans require you to pay a balance not covered. It is your responsibility to know what limitations, exclusions, deductibles, or co-pays your plan has. Your insurance policy is a contract between you, your employer, and the insurance company. We are NOT a party to that contract, and our financial relationship is with you, not your insurance company. It is also important to remember that an authorization is not a guarantee of coverage. If the policy does not cover the service and an authorization is obtained, it may not be paid and result in private liability to the family. Additionally, Community School will contact the insurance company to verify coverage as a courtesy to the family. This does not remove the responsibility from the family to know and understand their insurance coverage. If they do not pay or follow the coverage quotes to Community School, it remains the family’s responsibility to work with the insurance company

Private Pay
Community School can enter into a Private Pay Agreement. Intake and billing staff will send invoices on a monthly basis

Payment in Full
In some cases, a funding source may pay for only a portion of the charges. Unless specifically contracted, co-pays, discounted charges, and deductibles are the responsibility of the insured. Community School will prepare an invoice with outstanding charges due on a monthly basis. Insurance companies often discount rates to a “usual and customary” price. Unless contracted, Community School does not accept discounted rates.

Community School accepts cash, checks, money orders, and Credit/Debit Cards (Visa, MasterCard, Discover, and American Express) for payments. Declined payments will incur an additional fee of $25.00 that will be added to your bill.

Timely Payments & Delinquent Account

All payments shall be made within 30 days of the invoice date. An account is considered past due when payment is not received 30 days from the statement date. Unpaid accounts beyond 90 days are considered delinquent and may be forwarded to a collection agency unless other written arrangements have been agreed to. Legal costs and attorney’s fees incurred in collecting delinquent accounts will be the responsibility of the person responsible for the account. Additionally, any account that is over 30 days past due may result in services being put on hold and/or late fees. If the insurance company does not pay your balance in full within 30 days, we will ask that you contact your insurance company to help facilitate the processing of this payment. We understand that temporary financial problems may affect the timely payment of your balance. We encourage you to contact us so we can assist you in the management of your account.

Secondary Insurance

Community School will bill a secondary insurance in the same manner as a primary insurance source. In all cases, the Community School will bill the primary insurance first and the secondary insurance once the Community School has obtained the Explanation of Benefits (EOB) from the primary insurance.

Missed and Late Therapy Appointment Fees and holiday Survey Fees:

Community School makes the schedule changes for the entire staff by 8:00 am; therefore, all reported absences must be documented by 7:30 am or a half hour prior to your child’s start time. Daily schedule changes must be called into the Client Attendance Line (CAL) 318-780-4419 before 7:30 am OR a half hour before your child’s start time to prevent an attendance occurrence violation. When a schedule change is called into the CAL, a specific arrival/departure time must be given to ensure staff availability. Any schedule changes after the designated time will result in an attendance occurrence violation in which future therapy services may be suspended. Community School will not assess an attendance occurrence violation for children that Community School sends homesick.

Community School sends out attendance holiday surveys prior to each holiday that Community School will be closed. The information collected is used to assist the scheduling department in balancing the therapy staff and clients’ schedules to ensure that Community School has proper staff available to clients. If you have been surveyed as to which days around a holiday you plan on bringing your child to Community School and at the last-minute change your commitment to bring your child to Community School on the surveyed days, you will be charged a $50 surveyed-day cancellation fee. This fee will be applied to each day originally surveyed. If your child is sick, you will be charged unless a doctor’s note is provided to Community School for each day surveyed. If you change your mind and want to bring your child into therapy, approval from the Program Supervisor (PS) is required as staffing may not be available. Chronic absenteeism and tardiness will have a negative effect on your child’s therapeutic progress and may result in termination of service.

Divorce Decrees
Community School will not enter into any disputes between parents who have separated or divorced. One parent must agree to be the person responsible for the child’s account.

Interest and Late Charges
Community School reserves the right to charge interest up to the amount allowed by law for late payments.

Consequences for Non-Payment
Community School reserves the right to discharge your child from therapy or suspend therapy for unpaid services or accounts that are delinquent. If services are terminated or suspended, your child is placed on the waiting list and may begin services after the account is paid in full and payment for future services is established.

My signature indicates that I have received a copy of Community School's Financial Agreement and I have read and understand that I am responsible for my child’s account and agree to pay for services as indicated in this agreement. I understand that I am financially responsible for all the charges whether or not paid by insurance. I hereby authorize Community School to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions.

Signature of Parent/Guardian:   Signature
Date

Signature of Client (if applicable):   Signature
Date

Participating Staff Signature:   Signature
Date
Should be Empty:

	Yes?	Contact Name	Agency/County	Phone Number
Service
Social Worker/Case Manager
Other

	Yes	No
Does your child show an interest in peers?
Does your child engage in parallel play?
Does your child engage in cooperative play?
Does your child engage in age-appropriate toy play?
Does your child try to share his/her enjoyment with others?
Does your child try to comfort others when they are hurt or sad?
Does your child use a range of facial expressions?

	Yes	No	If so questions
Is your child verbal?
If yes: How many words does your child typically use at once?
Does your child ask for items verbally?
Does your child spontaneously label items?
Does your child ask questions?
Does your child answer questions?
Can your child engage in conversations?
Does your child use gestures?
Can your child follow instructions
If yes: How many steps can he/she follow at once?
Does your child appear to understand what you are saying?

	Yes	No	If so questions
Does your child become fixated on objects/activities?
Does your child struggle with changes in routines?
Does your child engage in repetitive toy play?
Does your child display ritualistic behaviors?
If yes, list examples:
Does your child engage in repetitive behaviors?
If yes, list examples:
What does your child do when upset?
Can your child follow instructions
If yes: How many steps can he/she follow at once?

Enrollment Packet

If you have any further questions or concerns, please contact us

Evaluations/ Assessments/ Required Documents

Child's Personal Information

Child's Race and Ethnicity

Parent/Guardian 1

Parent/Guardian 2

Diagnostic Information

Medical History

Emergency Contact Information (Page 1 of 2)

Emergency contacts other than parents/guardians:

**Please note a separate client release form needs to be filled out for the individuals noted for the emergency contacts and those who can pick up your child. See client release of information form at the end of the enrollment packet. **

Emergency Plan / Information (Page 2 of 2)

Child's Dentist

Child's Physician

Current Medications

Allergies (include additional sheets as necessary):

Emergency action plan for seizures & allergies:

Insurance Information

Primary Insurance

Secondary Insurance

History of Therapies Received

Speech Therapy

Occupational Therapy

Case Management Services

History of Therapies Received

Parent / Caregiver Intake Questionnaire

Tell us about your child

Check the box in each domain that best describes your child

Behavioral Characteristics of Your Child

Language

Current living situation

Family Members

Family Strengths

School Services

Technology Available (Check all that apply)

Check the box in each area that best describes you as a parent

Parent/Caregiver Training Preferences

General Information About Community School Services

ABA Therapy

Individualized Programming/Development

Verbal Behavior

Assessments - VB-MAPP, FBA, ABLLS-R, AFLS

FBA - A Functional Behavior Assessment

ABLLS-R - The Assessment of Basic Language and Learning Skills - Revised

AFLS - The Assessment of Functional Living Skills (AFLS)

Behavior Intervention Plans

Social Skills Training

Functional Communication Training

Professional Development Training (Parent/Tutor/Teacher)

School Consulting

IEP Development and Support

Orientation to Services

What does treatment look like?

When can I expect home visits?

How are appointments scheduled?

How are missed appointments handled?

Treatment Planning

What occurs upon the completion of treatment

Policy on Confidentiality

Mission Statement and Program Description

Holy Angel’s Mission Statement

Program Description

Client Rights and Responsibilities

Client Rights

You Have the Responsibility

Our Ethical Obligations

Consent for Treatment and Recipient’s Rights

AUTHORIZATION TO RELEASE INFORMATION

AUTHORIZATION TO BILL INSURANCE

Human Rights Notification

Client Grievance Procedures

Notice of Privacy Practices

Confidentiality

How to Contact your Service Providers

Privacy of Information Policies

Our Legal Duties

Use of Information

Duty to Warn and Protect

Public Safety

Please note a separate client release form needs to be filled out for the individuals noted for the emergency contacts and those who can pick up your child. See client release of information form at the end of the enrollment packet.