ABA Therapy Registration Form

Dear Prospective Client,

Thank you for your interest in our ABA clinic. The registration forms within provide us with information to assess how we can best serve your child and family. With these documents completed, we may begin the process on our end toward beginning treatment.

Once you have completed the documents, please upload a copy of your insurance card(s) front and back, comprehensive diagnostic report with a diagnosis of Autism Spectrum Disorder (F84.0) and the script or referral for ABA Services for Medicaid recipients (if these have not already been provided).

Once the registration is complete and we have received all of the needed documents, you will receive an email or a phone call with the next steps.

Should you have any questions, comments or concerns, please do not hesitate to contact us! Thank you again for your interest in our organization and we look forward to getting to know your family and child.

Our mission at Beyond the Spectrum is to serve the children and families in our community affected by autism and related disorders. By providing individualized therapeutic and educational services and utilizing the expertise of our professionally trained staff, our goal is for each child to achieve their highest potential in a safe, caring and family-friendly environment.

The Clinic at Beyond the Spectrum supports evidenced-based treatment methods based upon the procedures and principles of Applied Behavior Analysis (ABA) inclusive of Natural Environment Teaching (NET), Discrete Trial Instruction (DTI), Verbal Behavior strategies and Direct Instruction. We recognize the need to work with the families of our clients as well as collaborate with his/her other therapists. Each client has an individualized program designed to address his/her needs. Once we determine the client has met treatment eligibility requirements and assure our clinic is an appropriate placement for him/her, we begin the treatment process. In order to design a treatment package that best meets the client’s needs, our initial assessment includes but is not limited to Functional Behavior Assessments, Preference Assessments, VB-MAPP and ABLLS-R. Each skill area is designed to foster each child’s independence and functioning. Goals are established with the collaboration of parents/caregivers and other professionals as part of the multidisciplinary team.

Client's Name*

First NameLast Name

Child's Photo

DOB*

Date

Sex:

MaleFemale

Parent/Caregiver Name:*

First NameLast Name

Parent/Caregiver Name:

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Caregiver Phone # 1*

Please enter a valid phone number.

Parent/Caregiver Phone # 2

Please enter a valid phone number.

Parent/Caregiver email # 1*

example@example.com

Parent/Caregiver email # 2

example@example.com

Preferred method of Contact:

PhoneTextEmail

Medical Diagnosis*

Insurance Carrier and Insurance Member Number (Please upload a copy of insurance card with this intake form)*

Allergies/Special Diet/GI Issues:

Does your child have:

Skin ConditionsAsthmaSeizuresOther

If yes, please give a brief explanation:

Does your child sleep through the night?*

Does your child nap?*

Medication List (N/A if none)*

What are your ABA goals in the following areas: *

Primary Caregivers*

Living Arrangements*

Birthing history/Medical history/Surgeries/Hospitalizations

Does your child attend school? (N/A if no) Please upload IEP if available*

Does your child receive other services such as ABA (previous or current), OT, PT speech, music, respite, camp etc.?

Please list any significant events your child may have experienced (divorce, moves, abuse, birth of siblings, substance abuse, traumatic events, custody issues)

How does your child communicate their needs? Please select all that appy.*

Does your child refuse any hygiene care or routines (hair brushing, bathing, brushing teeth, clipping nails, doctor or dentist appointments)?

Does your child have any sensory concerns (noise, textures, etc.)

Describe your child's ability to do the Following: *

Does your child respond to their name?

YesNoSometimes

Can your child swim?

YesNo

Is your child toilet trained?*

Does your child dress independently?*

Does your child eat meals at the table? Use utensils? *

Do you have any concerns in the community or going outside?*

Does your child have awareness of danger?*

Does your child have specific behaviors concerns such as: aggression, mouthing, elopement, self -injury, property destruction, climbing, throwing, tantrums, etc.?*

Does your child have an FBA from school? Or a BIP from another ABA provider? If YES, please attach a copy.*

YesNo

File Upload

Does your child have an IEP? If YES, please attach a copy.*

YesNo

File Upload

Does your child have a comprehensive diagnosis evaluation (CDE)? Often this is the ADOS assessment. Please attach a copy of your child's diagnosis report and referral or script from doctor for ABA services.*

YesNo

File Upload

What are your child's favorite toys, foods, items, activities?*

Please explain any routines/structure/organization you currently have in place. *

Please share any customs, religious beliefs, cultural norms that may impact treatment.

Additional Emergency Contacts*

I give permission for the following people to pick up my child(only add people not listed above)*

1) No child will be released to any person whose name does not appear on this Authorization Pick-Up List

2) Before any person can remove a child, proper ID, such as a current driver’s license, must be shown

3) If there is ever any question as to the identification of any person attempting to remove a child from the premises, the legal guardian will be notified immediately

4) The legal parent/guardian must give advanced written authorization before any person not appearing on our Authorized Pick-Up List will be allowed to remove a child from the premises

5) In the event of an emergency, the legal parent/guardian may give above stated permission verbally, but only if given directly to the Administrator or authorized office personnel.

Beyond the Spectrum defines legal parents or legal guardian to be person(s) who enrolled the child and whose signature is indicated at the bottom of this form. In the case where a divorce or legal separation has occurred or is in the process, legal court documentation must be presented as proof of who is awarded temporary or permanent custody of the child in question. The safety of the minor child in our custody will always take top priority in any situation. Only official court documents, whose authenticity has been verified will supersede any other documents received or placed on file.

Name:*

Signature*

Seizure Plan - Only complete if your child has a seizure disorder.

Seizure First Aid

Keep Calm, provide reassurance, remove bystandersKeep airway clear, turn on side if possible, nothing in mouthKeep safe, remove objects, do not restrainObserve and record time and durationOther

Call 911 if:

Generalized seizure longer than 5 mins.2 or more seizures without recovering between seizures.As needed treatments don't work.Injury occurs or is suspected, or seizure occurs in water.Breathing, heart rate or behavior doesn't return to normal.Unexplained fever, or pain, hours or a few days after a seizure.Other

When seizures require additional help:

As the parent or legal guardian of Child's name*, I understand and acknowledge the following

Non-Emergency/Less Critical Situations: In the event that my child suffers a minor
injury or illness, such that basic first-aid techniques are required but not to the extent that they require emergency medical personnel (ex. isolated instances of vomiting; minor scrapes and cuts), trained staff will administer basic first-aid, an incident report will be documented as soon as possible and I (the parent/guardian indicated as first emergency contact) will be notified as soon as possible by a clinic supervisor.

EMERGENCY NOTIFICATION PREFERENCE – Please identify which of the following options you would prefer in the case of a medical emergency:

Call 911/Emergency Medical Services first, then notify me (the parent/guardian indicated as first emergency contact).Notify me (the parent/guardian indicated as first emergency contact) first, then call 911 if parents/guardians cannot be reached immediately.

Preferred hospital (if any)

Transportation in Case of Medical Emergency: While the clinic will attempt to
transport my child to the preferred hospital, I understand that in certain emergency
situations, the nearest hospital might be chosen based on the discretion of the
emergency medical personnel.

Incident Report: In the case of any medical attention being provided, non-emergency or emergency, an incident report will be documented as soon as possible. A copy of all incident reports will be made for the possession of any of the individuals released upon request.

Name:*

Signature*

AUTHORIZATION TO BILL INSURANCE

I hereby give my consent for the ABA Clinic at Beyond the Spectrum 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 the ABA Clinic at Beyond the Spectrum any deductible or uncovered charge in accordance with my health care plan including the assessment fee if I choose not to proceed with services provided by the ABA clinic at Beyond the Spectrum.

Name:*

Signature*

AUTHORIZATION TO RELEASE MEDICAL INFORMATION TO INSURANCE CARRIER

I understand that my express consent is required to release any health care information relating to assessment and treatment. I hereby give my consent for the ABA Clinic at Beyond the Spectrum to release medical and all other relevant information to our insurance carrier as required by my insurance carrier to process medical billings.

Name:*

Signature*

STATEMENT OF AUTHORITY TO CONSENT

I certify that I have the authority to legally consent to assessment, release of information, and all legal issues involving the above-named individual. Upon request, I will provide the ABA clinic at Beyond the Spectrum with the proper documentation to support this claim. I further hereby agree that if my status as legal guardian should change, I will immediately inform the Analyst of this change in status and will further immediately inform the Analyst of the name, address, and phone number of the person(s) who have assumed guardianship of the above-named individual.

I also consent release to contact the following named people in order to discuss relevant information pertinent to intervention. *

Name:*

Signature*

TREATMENT CONSENT FORM FOR ABA SERVICES

I consent for behavioral treatment to be provided for the above-named individual by the ABA clinic at Beyond the Spectrum. I understand that the procedures used will consist of manipulating antecedents and consequences to produce improvements in behavior; however, at the beginning of treatment behavior may get worse in the environment where the treatment is being provided or in other settings. As part of the behavioral treatment, physical prompting and manual guidance may be used. The actual treatment protocols, which will be used, have been explained to me.

Name:*

Signature*

INDIVIDUAL/CAREGIVER AND PROVIDER CONTRACT

1. I understand that once the behavior program is developed, it will be up to me and the therapists to implement the majority of the intervention.

2. I understand that I may need to change some house/family routines to improve the individual's behavior.

3. I agree to take data on the individual's behavior as requested.

4. I agree to attend scheduled caregiver guidance meetings.

I understand that in order for this intervention to be successful, I may be required to put forth individual effort

Name:*

Signature*

CONFIDENTIALITY ACT/ABUSE REPORTING PROTOCOL

I understand that all information related to the above-named individual's assessment and treatment must be handled with strict confidentiality. No information related to the individual, either verbal or written, will be released to other agencies or individuals without the express written consent of the individual'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 report or suspected, the professional involved in required to report it to the Department of Children & 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 and staff testimony are subpoenaed by court order, we are required to produce records or appear in court and answer questions regarding the individual.

Name:*

Signature*

GRIEVANCE/ DISCHARGE PROCEDURE

Grievance: If you are not satisfied with the services you receive from the staff assigned to you, please first call the behavior analyst assigned to your case. If you have a grievance with the BCBA/BCaBA/RBT or are not satisfied with the manner in which your concerns are being addressed, you may contact the Director of Clinical Services - Amy Labrie. If the issue is not resolved, the services may be terminated.

Discharge: The behavior analyst reserves the right to discontinue or discharge treatment in the instances of:

1. Any parent or caregiver that refuses to follow a treatment plan and has been reminded of the contract they signed stating that it is indeed the family's responsibility to follow a plan.

2. Any child who ages out of coverage (22 yrs. and no longer in school)

3. Any individual that is not improving in spite of exhausting all known interventions, procedures, and or research- based strategies.

4. Goals have been met and maintained; therapy faded.

5. Violation outlined in the Cancellation/No Show Policy

6. Failure to pay for services.

If an individual is discharged, it is best practice that the analyst provide a list of other providers and professionals in their area with the background and expertise to provide support services to the individual and their family.

Disclaimer: The analyst will in no way turn down a family for coverage, nor will they discharge or discontinue treatment on the basis of race, creed, sexual orientation, wealth, etc.

Name:*

Signature*

CANCELLATION/ NO SHOW /CHANGE IN APPOINTMENT POLICY

Regular attendance is required for our services to be effective. Irregular attendance costs both the assigned staff and the overall program time and money. It is therefore the responsibility of the individual and or his/her legal guardian to attend all scheduled appointments.

Changes in Schedule - If there is a change in schedule such as an appointment, but the student will still be attending the clinic for part of the scheduled session, please provide a written notice. The written notice needs to be sent to the program director at least 24 hours prior to the start of the day. Without this alert there is a chance that your child may not be able to receive the one-on-one therapy due to staff availability. This includes early dismissals that were not scheduled prior. Changes in schedule that are not communicated 24 hours in advance may risk availability of your child's therapst and a session for that day. Repeated schedule changes that are not communicated risk your child being placed back on our waitlist.

If there is an unexpected situation and you are going to be late dropping off your child, please email the scheduling manager directly. The ABA Clinic at Beyond the Spectrum gives the parent 30 minutes from the student’s scheduled start time before cancelling the session. After 30 minutes, the session will be cancelled. Repeated tardiness will be tracked. If this becomes a concern, you may be asked to change your child’s therapy time to a later session time.

Repeated tardiness is defined as being late for your session (more than 15 minutes) 2x/month. If you exceed twice a month being tardy even with alerting the center director, and you continue to be late, Your child may be placed back on our waitlist.

No-Show Policy - Should a child miss therapy with no previous call from the family to the scheduling manager, the parents will be documented with a no call/no show. 3 documented no call no shows may place your child’s services on hold and your child will be placed back on our waitlist.

If your child attends school, it is your responsibility to inform both the school and the ABA clinic that your child will be late/out/picked up early.

I understand these cancellation/no show/ service delivery policies and agree to its terms.

Name:*

Signature*

FINANCIAL RESPONSIBILITY

For Clients Without Insurance or Active Authorizations:

• No Insurance? Clients without insurance should pay every two weeks. You'll get an invoice, and it should be paid within 14 days.

• No Active Authorization? If you don't have an active authorization, any charges you incur outside the authorized period are your responsibility. You might be able to get reimbursed from your insurance if they eventually approve the services, but we'll still charge the out-of-pocket rate.

For Insured Clients:

• Got New Insurance? If your insurance changes, let us know and provide us with your new card. Remember, when insurance switches, sometimes services need to be re-assessed, and a new behavior plan might have to be submitted. This is important to ensure there's no gap in your child's treatment.

• Check Our Network Status: Always make sure we're still an "in-network" provider with your insurance. We'll do our part by submitting necessary forms and billing secondary insurances if needed.

For HMO or Managed Care Plan Clients:

• Your Share: You're responsible for any co-payments or parts of charges that your plan says you must pay.

• Payments: You'll get an invoice by mid-month, and any copayments or deductible balances should be paid by the start of the next month. Our financial director will charge your saved card on the 1st for the invoice balance.

• Referrals: If your insurance requires referrals for treatments, make sure we have it when you come for therapy. If we don't have the needed referral, we might need to reschedule or you could be responsible for the charges.

• Unresolved Balances: If there's a remaining balance that isn't resolved, either through full payment or a payment plan, and you decide to stop services, we might have to send your account to an outside collection agency.

For in-Network Plan Clients:

• Your Share: Like the HMO clients, you're responsible for any co-payments or parts of charges that your plan dictates.

• Non-Covered Services: If there are services that your insurance doesn't cover, they're your responsibility. Please pay in full when you get the invoice. If you have questions about what's covered, reach out to your insurance's member services department.

Remember, we're here to help. If any part of this is unclear, or you're facing financial challenges, please speak to us. We're dedicated to ensuring that your child receives the care they need.

Notification of Benefits and Credit Card on File:

• I have read and understand my notification of benefits. I have been provided a copy for review and have had the opportunity to ask questions for clarification as needed.

• I agree to keep a credit card on file to be charged at the first of the month for any outstanding invoices.

FES Scholarship Payments:

• If a family has FES funding, the family is responsible for any out of pocket, deductible or invoice payments paid directly to Beyond the Spectrum upon invoice date. It is the responsibility of the family to submit for reimbursement through FES. Beyond the Spectrum is not responsible for invoices not reimbursed through FES.

Remember, we're here to help. If any part of this is unclear, or you're facing financial challenges, please speak to us. We're dedicated to ensuring that your child receives the care they need.

Credit Card Authorization Form: *Your card will be charged for the total amount on your statement on the first of each month. By signing this form, you authorize Beyond the Spectrum to charge your card for the amount listed on the statement* If Medicaid is your insurance provider you can please enter N/A. *

Name:*

Signature*

CLIENT NOTIFICATION OF PRIVACY OF RIGHTS

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPPA) NOTICE OF PRIVACY PRACTICES

This Notice of Private Practice describes how the ABA Clinic at Beyond the Spectrum may use and disclose your protected health information (PHI) to carry out treatment, payment, or healthcare operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. PHI is information about you, including demographic information that may identify you and that related to your past, present or future physical or mental health condition and related health care services.

Uses and Disclosures of PHI - Your PHI may be used and disclosed by your physician, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to may your health care bills, to support the operation of the physician's practice and any other use required by law.

Treatment - We will use and disclose your PHI to provide, coordinate or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your PHI as necessary, to a home health agency that provides care for you or shared with a physician to whim you have referred, to ensure that the physician has the necessary information to diagnose or treat you.

Payment - Your PHI will be used, as necessary, to obtain payment for your health care services. For example, obtaining approval for therapy services that may require that your relevant PHI be disclosed to obtain approval for the approved therapy services.

Healthcare Operations - We may use or disclose, as is necessary, your PHI in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training or medical students, licensing and conducting or arranging for the other business activities. For example, we may disclose your PHI to medical school students that see patients at our office or we may use sign-in sheets at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the lobby when you are waiting to see your physician. We may use your PHI to contact you to remind you of your appointment.

Your PHI may be used in the following situations with or without authorization. These situations include: as required by law, public health issues as required by law, communicable disease, health oversight, abuse or neglect, Food and Drug Administration requirements, legal proceedings, law enforcement, criminal activity, workers compensation, required uses and disclosures: under the law we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of section 164-500.

Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object unless required by law. You may revoke the authorization at any time in writing, except to the extent that your provider or the ABA provider's practice has taken an action in reliance on the use or disclosure indicated in the authorization.

You have the right to request a restriction of your PHI. This means you may ask us not to use or disclose any part of your PHI for the purpose of treatment, payment or healthcare operations. You may also request that any part of your PHI not be disclosed to a family member or friends who may be involved in your care or for notification purposes as described In the Notice of Privacy Practices, your request must state that specific restrictions requested and to whom you want to restrictions to apply.

HIPPA and Service Agreement Your signature(s) below indicates that you have read the information in this document and agree to be bound by its terms and that you have received the HIPPA notice described above or have been offered and declined. Consent by all parents/legal guardians is required.

Name:*

Signature*

I give permission and consent for The ABA Clinic at Beyond the Spectrum to photograph for the following purposes:

Name:*

Signature*

PERMISSION TO VIDEOTAPE OR AUDIOTAPE

I give permission and consent for the ABA Clinic at Beyond the Spectrum to videotape and/or audio tape my child 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 Beyond the Spectrum.

Name:*

Signature*