Coaching New Client Intake Forms with DERS-P/FAST

Please review!
Signing below, I understand the differences between the Medical Model and the Social Model. I am making the choice to engaging in The Happy Medium Approach, Social Model Coaching.*

Yes
Guardian Name*

First NameLast Name
Child Name*

First NameLast Name
Signature*

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Date*

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Understanding the Coaching Relationship
Description of Coaching: Coaching is a partnership (defined as an alliance, not a legal business partnership) between the Coach and the Client in a thought-provoking and creative process that inspires the client to find workable tools for life across self, social, and community domains.

1) Coach-Client Relationship

A. Coach agrees to maintain the ethics and standards of behavior established by the Behavior Analysis Certification Board (www.bacb.com). It is recommended that the Client review the BACB code of Ethics and the applicable standards of behavior.

B. Client is solely responsible for creating and implementing his/her or their own physical, mental and emotional well-being, decisions, choices, actions and results arising out of or resulting from the coaching relationship and his/her or their coaching calls and interactions with the Coach. As such, the Client agrees that the Coach is not and will not be liable or responsible for any actions or inaction, or for any direct or indirect result of any services provided by the Coach. Client understands coaching is not therapy and does not substitute for therapy if needed, and does not prevent, cure, or treat any mental disorder or medical disease.

C. Client further acknowledges that he/she/they may terminate or discontinue the coaching relationship at any time.

D. Client acknowledges that coaching is a comprehensive process that may involve different areas of his/her/their life, including parenting, emotional capacities, emotional regulation, education, familial relationships, and recreation. The Client agrees that deciding how to handle these issues, incorporate coaching principles into those areas and implementing choices is exclusively the Client’s responsibility.

E. Client acknowledges that coaching does not involve the diagnosis or treatment of medical or mental disorders as defined by the American Psychiatric Association or the DSM-5 and that coaching is not to be used as a substitute for counseling, psychotherapy, psychoanalysis, mental health care, substance abuse treatment, or other professional advice by legal, medical or other qualified professionals and that it is the Client’s exclusive responsibility to seek such independent professional guidance as needed. If the Client is currently under the care of a mental health professional, it is recommended that the Client promptly inform the mental health care provider of the nature and extent of the coaching relationship agreed upon by the Client
and the Coach.

F. The Client understands that in order to enhance the coaching relationship, the Client agrees to communicate honestly, be open to feedback and assistance and to create the time and energy to participate fully in the program.

2) Services

The parties agree to engage in a week-to-week Coaching Program through Tele-coaching or in person meetings at a rate of

Rosalie Prendergast, $200
Katherine Thomas, $160

Erin Marble, $160
BCBA with 2 Years or less experience $140
Ann Braccia, $80
Behavior Technician, $60

**some coaches require at least 5% of their total hours to be supervised by a BCBA for their certification. Your team will inform you if this applies to them**

BCBA travel is $40 per hour traveled

RBT is round trip mileage based on the IRS mileage rate

The coach will be available to the Client by e-mail and text in between scheduled meetings as defined by the Coach:

3) Schedule and Fees

This coaching agreement is valid as of the date of signature. The fee

Rosalie Prendergast, $200
Katherine Thomas, $160

Erin Marble, $160
BCBA with 2 Years or less experience $140
Ann Braccia, $80
Behavior Technician, $60

**some coaches require at least 5% of their total hours to be supervised by a BCBA for their certification. Your team will inform you if this applies to them**

BCBA travel is $40 per hour traveled

RBT is round trip mileage based on the IRS mileage rate

The calls/meetings shall be at variable lengths depending on client needs. If rates change before this agreement has been signed and dated, the prevailing rates will
apply.

4) Procedure

The time of the coaching meetings and/or location will be determined by Coach and Client based on a mutually agreed upon time. The client and the coach will meet on the Zoom link or in person at the schedule time.

5) Confidentiality

This coaching relationship, as well as all information (documented or verbal) that the Client shares with the Coach as part of this relationship, is bound by the principles of confidentiality set forth by the BACB (www.bacb.com). However, please be aware that the Coach-Client relationship is not considered a legally confidential relationship (like the medical and legal professions) and thus communications are not subject to the protection of any legally recognized privilege. The Coach agrees not to disclose any
information pertaining to the Client without the Client’s written consent. The Coach will not disclose the Client’s name as a reference without the Client’s consent.
Confidential Information does not include information that: (a) was in the Coach’s possession prior to its being furnished by the Client; (b) is generally known to the public or in the Client’s industry; (c) is obtained by the Coach from a third party, without breach of any obligation to the Client; (d) is independently developed by the Coach without use of or reference to the Client’s confidential information; or (e) the Coach is required by statute, lawfully issued subpoena, or by court order to disclose; (f) is disclosed to the Coach and as a result of such disclosure the Coach reasonably believes there to be an imminent or likely risk of danger or harm to the Client or others; and (g) involves illegal activity. The Client also acknowledges his or her continuing obligation to raise any confidentiality questions or concerns with the Coach in a timely manner.

6) Release of Information

If the client wishes to release information to a 3rd party, they will complete a release of information form prior to the coach releasing information.

7) Cancellation Policy

Client agrees that it is the Client's responsibility to notify the Coach 24 hours in advance of the scheduled calls/meetings. Coach reserves the right to bill the Client for a missed meeting. The coach will attempt in good faith to reschedule the missed meeting.

9) Termination

Either the Client or the Coach may terminate this Agreement at any time with written notice. Client agrees to compensate the Coach for all coaching services rendered through and including the effective date of termination of the coaching relationship.

10) Limited Liability

Except as expressly provided in this Agreement, the Coach makes no guarantees, representations or warranties of any kind or nature, express or implied with respect to the coaching services negotiated, agreed upon and rendered. In no event shall the coach be liable to the Client for any indirect, consequential or special damages. Notwithstanding any damages that the Client may incur, the Coach’s entire liability under this Agreement, and the Client’s exclusive remedy, shall be limited to the
amount actually paid by the Client to the Coach under this Agreement for all coaching services rendered through and including the termination date.

11) Entire Agreement

This document reflects the entire agreement between the Coach and the Client, and reflects a complete understanding of the parties with respect to the subject matter. This Agreement supersedes all prior written and oral representations. The Agreement may not be amended, altered or supplemented except in writing signed by both the Coach and the Client.

12) Dispute Resolution

If a dispute arises out of this Agreement that cannot be resolved by mutual consent, the Client and Coach agree to attempt to mediate in good faith for up to 30 days after notice given. If the dispute is not so resolved, and in the event of legal action, the prevailing party shall be entitled to recover attorney’s fees and court costs from the other party.

13) Severability

If any provision of this Agreement shall be held to be invalid or unenforceable for any reason, the remaining provisions shall continue to be valid and enforceable. If the Court finds that any provision of this Agreement is invalid or unenforceable, but that by limiting such provision it would become valid and enforceable, then such provision shall be deemed to be written, construed, and enforced as so limited.

14) Waiver

The failure of either party to enforce any provision of this Agreement shall not be construed as a waiver or limitation of that party's right to subsequently enforce and compel strict compliance with every provision of this Agreement.

15) Applicable Law

This Agreement shall be governed and construed in accordance with the laws of the State of Colorado, without giving effect to any conflicts of laws provisions.

16) Binding Effect

This Agreement shall be binding upon the parties hereto and their respective successors and permissible assign.
Guardian Name*

First NameLast Name
Child Name*

First NameLast Name
Signature*

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Date*

MonthDayYear
Date

General Information*


Child's Name
Preferred Pronouns
Date of Birth
Child's Address
Phone Number
Email
Parent(S) Names

Consent to Coach

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

Rosalie Prendergast, MS BCBA

Katherine Thomas, MS BCBA

Erin Marble, MS BCBA

Ann Braccia, RBT

Registered Behavior Technicians or Behavior Specialists
Full Name Guardian*

First NameLast Name
Child Name*

First NameLast Name
Guardian Signature*

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Fee Schedule

Coaching with:

Rosalie Prendergast, $200
Katherine Thomas, $160

Erin Marble, $160
BCBA with 2 Years or less experience $140
Ann Braccia, $80
Behavior Technician, $60

**Registered behavior technicians and behavior technicians require at least 5% of their time to be supervised by a BCBA**

BCBA travel is $40 per hour traveled

RBT is round trip mileage based on the IRS mileage rate

Please sign in your understanding of the cost of coaching
Signature*

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Date*

MonthDayYear
Date
Guardian Name*

First NameLast Name

Payment Policy

Coaching is fee for service, you will be billed monthly via our QuickBooks online accounting system. You will receive a bill between the 1st and 4th of the month following services. Payment for these services is due upon receipt of the invoice from Eclipse Therapy, LLC DBA The Happy Medium Approach.

All account balances must be satisfied within 30 days of the date services were billed, after that time a re-billing fee of $10.00 may be charged to your account. If you have any questions regarding our financial policy, please do not hesitate to discuss them with us.

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

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

Super Bills

Eclipse Therapy, LLC DBA The Happy Medium Approach is not providing treatment services under the Medical Model and will not provide a super bill. The client is welcome to see if their insurance covers coaching service, and coaches will be paid at their current coaching rate to support efforts to receive reimbursement if the individual's plan does cover coaching costs.
Guardian Name*

First NameLast Name
Signature*

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Date*

MonthDayYear
Date

	Information
Name of Person Completing this form
Legal Name of Child/Adolescent
Nickname or name child routinely goes by
Child's date of birth
Current Age
Age of Diagnosis
Home Address (primary)
Home Address (secondary)
Home telephone (primary)
Home telephone (secondary)
Current School
Grade in School
School Phone Number

	Information
Who has physical custody
Who has legal custody

	Information
Name
Date of birth
Age
SSN
Occupation
Employer
Email
Education Completed
Health Conditions

	Information
Name
Date of birth
Age
SSN
Occupation
Employer
Email
Education Completed
Health Conditions

	Information
Name
Date of birth
Age
SSN
Occupation
Employer
Email
Education Completed
Health Conditions

	Information
Name
Date of birth
Age
SSN
Occupation
Employer
Email
Education Completed
Health Conditions

	Information
Child's Height
Child's Weight
Does the child have any vision problems
Does the child have any hearing problems

	Information
Name
Practice Name
Address
Phone Number
Fax

	Information
School Name
Current Teacher
Does your child's teacher have concerns?
Does your child have a favorite subject
Does your child have a least favorite subject
Current IEP
Current 504
Physical Therapy
Adaptive Technology
Occupational Therapy
Behavior Intervention Plan
Consultation from a Psychologist
Self Contained Room
Team Taught Classes
Pull Out
Special Program

	Information
Minecraft
Video games
Sports
Karate
Scouts
Dance
Gymnastics
Coding
Music
Art
Others

Do you have any motor concerns? Gross motor or fine motor?*

	Yes	No
Autism Spectrum Disorder
Learning Problems
ADHD ADD Attention
Depression
Bipolar
Behavior Problems
Psychosis
Substance Abuse
Other Mental Health

	Date	Doctor	Diagnosis	Very Satisfied
Evaluation 1
Evaluation 2
Evaluation 3
Evaluation 4

	Yes	No
Problems with eating
Isolated socially from peers
Problems making friends
Problems getting to sleep
Problems controlling temper
Nightmares
Bed-wetting
Problems with authority
Anxiety
Unmotivated
School concentration difficulties
Sadness or Depression
Substance abuse

	Date	Hospital	Length of stay	Reason
Hospitalization 1
Hospitalization 2
Hospitalization 3
Hospitalization 4

	Name	Dose	Desired Effects
Medication 1
Medication 2
Medication 3
Medication 4

Understanding the Coaching Relationship

Super Bills

Leisure, Academic, and Social

Challenging Behavior

Emotions

Language

Sensory

FAST

	Yes	No
Count to 10
Count to 20
Count to 20+
Can your child count out a number of objects up to 10+
Can he/she complete simple addition math problems? (Single digit)
Can he/she complete simple subtraction problems?

	Yes	No
Identify blends (e.g. sh, st, cr)
Can sound out words with blends
Can read simple words (2-4 letter simple words - cat, dog, sat)
Can read longer words and sight words (there, just, jump)
Can sound out unknown words
Can read simple sentences
Can comprehend what he/she is reading (can understand and answer questions about what's been read)

	All	Sometimes	None
Does your child bathe him/herself?
Grooming (brushing teeth, combing hair)
Does your child clean up after him/herself
Dress themselves
Do you have safety concerns

	All	Sometimes	None
Answer or look when name is called
Does your child follow gestures from others
Does your child engage in activities or games that are not their idea
Can your child appropriately play by themselves ?
Do you have safety concerns
Can your child answer questions when there is background noise, other people, distraction?
Does your child appear to understand directions and questions?
Does your child appear to have a good memory?
Can your child share control with others?
Does your child play with other children?

	Severe	Moderate	Mild	Does Not Apply
Tantrums
Aggression
Self Injury
Running away
Destroying Property
Perseveration
Transitions
Dropping to the floor

	Yes	No
When told "no" (you can't have that/can't do that)
When he/she is not getting attention or wants attention
To avoid non preferred activities
To escape a non preferred task/activity
For no obvious reason

	Yes	No
Fear
Anxiety
Transition refusal
Dysregulation
Sadness
Emberasement

	Yes	No
Speak in full sentences
Use language before big behaviors
Communicate back and forth using language
Get their basic needs met using language
Use language to express emotions

	Yes	No
Light
Sound
Texture
Temperature
Fast environments
Food
Activity levels

	1 Almost never (0-10%)	2 Sometimes (11-35%)	3 About half the time (36-65%)	4 Most of the time (66-90%)	5 Almost Always (91-100%)
1. My child is clear about his/her feelings
2. My child pays attention to how he/she feels
3. My child experiences his/her emotions as overwhelming and out of control
4. My child has no idea how he/she is feeling
5. My child has difficulty making sense out of his/her feelings
6. My child is attentive to his/her feelings
7. My child knows exactly how he/she is feeling
8. My child cares about what he/she is feeling
9. My child is confused about how he/she feels
10. When my child is upset, he/she acknowledges his/her emotions
11. When my child is upset, he/she becomes angry with him/herself for feeling that way
12. When my child is upset, he/she becomes embarrassed for feeling that way
13. When my child is upset, he/she has difficulty getting work done
14. When my child is upset, he/she becomes out of control
15. When my child is upset, he/she believes that he/she will remain that way for a long time
16. When my child is upset, he/she believes that he/she will end up feeling very depressed
17. When my child is upset, he/she believes that his/her feelings are valid and important
18. When my child is upset, he/she has difficulty focusing on other things
19. When my child is upset, he/she feels out of control
20. When my child is upset, he/she can still get things done
21. When my child is upset, he/she feels ashamed with him/herself for feeling that way
22. When my child is upset, he/she knows that he/she can find a way to eventually feel better
23. When my child is upset, he/she feels like he/she is weak
24. When my child is upset, he/she feels like he/she can remain in control of his/her behaviors
25. When my child is upset, he/she feels guilty for feeling that way
26. When my child is upset, he/she has difficulty concentrating
27. When my child is upset, he/she has difficulty controlling his/her behaviors
28. When my child is upset, he/she believes that there is nothing he/she can do to make him/ herself feel better
29. When my child is upset, he/she becomes irritated with him/herself for feeling that way
30. When my child is upset, he/she starts to feel very bad about him/herself
31. When my child is upset, he/she believes that wallowing in it is all he/she can do
32. When my child is upset, he/she loses control over his/her behaviors
33. When my child is upset, he/she has difficulty thinking about anything else
34. When my child is upset, he/she takes time to figure out what he/she is really feeling
35. When my child is upset, it takes him/her a long time to feel better
36. When my child is upset, his/her emotions feel overwhelming

	Yes	No
Psychological
Educational

	All	Sometimes	None
Single digit numbers 1-10
Double digit 10-99
Higher

	All	Sometimes	None
Single digit numbers 1-10
Double digit 10-99
Higher

	Yes	No	NA
Does the problem behavior occur when the person is not receiving attention or when caregivers are paying attention to someone else?
Does the problem behavior occur when the person’s requests for preferred items or activities are denied or when these are taken away?
When the problem behavior occurs, do caregivers usually try to calm the person down or involve the person in preferred activities?
Is the person usually well behaved when (s)he is getting lots of attention or when preferred activities are freely available?
Does the person usually fuss or resist when (s)he is asked to perform a task or to participate in activities?
Does the problem behavior occur when the person is asked to perform a task or to participate in activities?
If the problem behavior occurs while tasks are being presented, is the person usually given a “break” from tasks?
Is the person usually well behaved when (s)he is not required to do anything?
Does the problem behavior occur even when no one is nearby or watching?
Does the person engage in the problem behavior even when leisure activities are available?
Does the problem behavior appear to be a form of “self-stimulation?”
Is the problem behavior less likely to occur when sensory stimulating activities are presented?
3. Is the problem behavior cyclical, occurring for several days and then stopping?
. Does the person have recurring painful conditions such as ear infections or allergies? If so, list:_____________________________
Is the problem behavior more likely to occur when the person is ill?
If the person is experiencing physical problems, and these are treated, does the problem behavior usually go away?