Social Skills Client Service Agreement

 

Dear Caregivers,

 

Welcome to MASS Services! Our mission is to support individuals in achieving their full potential by using evidence-based Applied Behavior Analysis (ABA) strategies that are tailored to everyone's unique needs and strengths. We believe that everyone has the potential to lead a fulfilling life, and we are committed to helping individuals overcome barriers and achieve their goals.

At our organization, we take a personalized approach to every client we serve. We understand that every individual is unique, and we tailor our services to meet their specific needs and strengths. Our team of highly trained and experienced professionals uses evidence-based ABA strategies to promote skill development and independence in a variety of functional and community settings.

We are dedicated to empowering individuals to develop the skills they need to be independent, socialize with others, and participate meaningfully in their communities. We believe that everyone deserves the opportunity to live a happy, fulfilling life, and we are committed to helping individuals achieve that goal.

Our services are 100% integrated in functional and community settings, which means that we work closely with our clients in their natural environments to ensure that they can generalize their skills and thrive in the real world. We believe that this approach is essential to promoting long-term success and independence for our clients.

Thank you for choosing MASS Services LLC. We are grateful to have you here and we look forward to serving you!

Jasemine M Lakey MS BCBA

Chief Executive Officer

www.masssvcs.com

 

Diversity, Equity, & Inclusion

 

At MASS Services LLC, we are dedicated to fostering an inclusive environment where every individual's unique talent, experiences, and perspectives are valued. Our commitment lies in promoting diversity, equality, and inclusion across all aspects of our organization. We strive to cultivate a workplace where everyone feels welcomed, respected, and empowered. By embracing the diversity within our workforce, we aim to harness its full potential to drive success for both our clients and our staff.

 

Our Clinical Services Framework

→  Social Skills →  RBT →  BCBA Supervision

 

Excessive cancellations have been shown to disrupt programming and may negatively impact clinical quality. Except in cases of emergency, 24 hours' notice is required for all canceled appointments. In addition, we request that families give us at least two weeks' notice on all permanent scheduling changes to facilitate consistency in service delivery.

 

CANCELLATION POLICY UPON REQUEST.

Clinical Department

Each child is assigned a Clinical Team as follows:

• Board Certified Behavior Analyst
• Clinical Supervisor* * (excluding two-tier model insurance providers)
• Behavior Technician

I {parentguardianPrinted}, agree to have my child evaluated/treated at MASS Services LLC. I understand that the services that my child will receive are based on an applied behavior analysis (ABA) treatment model and that they will be provided by professionals trained in ABA. I understand that state laws may require that confidentiality be broken under certain circumstances - Specifically, if I am judged by the behavior analyst to be of danger to myself and/or others, gravely disabled, or if there is suspected child abuse.

I also understand that MASS Services LLC specializes in the evaluation and treatment of maladaptive behaviors as well as the teaching of socially significant life skills, and that if MASS Services LLC is unable to meet my family's specific needs, I will be referred to an appropriate agency or individual who may be a better fit.

Services: MASS Services LLC implements services rooted in the science of Applied Behavior Analysis. A variety of techniques are integrated and utilized during treatment. Children under the age of 18 will require a parent's signature (or legal guardian) to receive any form of treatment.

Any concerns that have not been resolved by the assigned clinical team within two weeks should be directed to our Clinical Director at jlakey@masssvcs.com

Your cooperation on the following is integral to the success of your child. MASS Services LLC sets the following expectations to promote a collaborative and supportive relationship between each client's family and their Clinical Team.

 

Wellness Policy

At MASS Services, the health and safety of our clients and staff are a top priority. If your child is sick, please notify your Clinical Team with as much notice as possible so that your therapy session can be rescheduled. We ask that parents follow the same guidelines used at school—if a child (or sibling) is too sick to attend school, they are also too sick to participate in therapy sessions.

If the client arrives at the center and is found to be ill, the session will be canceled and rescheduled. Similarly, if a child shows signs of illness while attending a session at the center, a parent or emergency contact will be called for immediate pick-up. Until they are picked up, the child will remain in the designated lobby area under staff supervision to ensure the safety of other staff and clients.

Our Wellness Policy includes, but is not limited to, the following symptoms:

 

• Temperature above 100
• Communicable Disease (i.e., the common cold or the flu, cough, runny nose)
• Hand/Foot/Mouth Disease
• Vomiting
• Measles, Mumps, Chicken Pox
• Diarrhea
• Sore Throat
• Lice
• Rash
• Pink Eye
• Covid-19
• RSV

 

Safety

MASS Services LLC staffis notpermittedtoridein thecarwitha parent, or allow a client or client's family to ride in the employee's vehicle, no matter who is driving, under any circumstances.

In case of an accident or unusual incident, the Technician will complete a Special Incident Report. The family, the Clinical Team, and the Regional Clinical Director will be informed within one [1] business day and a copy of the executed SIR will be distributed to all parties within 72 hours following the event.

 

Relationship

Parents and staff should be respectful and courteous toward each other. Discrimination or hostility toward a MASS Services LLC staff member will not be tolerated.

Open communication between parents and their child's Clinical Team is essential to the establishment of a successful program for the child. If there are any programming questions or concerns, please contact your child's Clinical Supervisor or Behavior Analyst to collaborate on a resolution.

Clinical Practices

1. MASS Services LLC will provide evidence-based applied behavior analysis therapy that is consistent with the principles of ABA, informed and updated with the most up-to-date research adapted to the individual, their behaviors of excess, skill deficits and their values.

2. Staff will adhere to all professional and ethical guidelines set forth by the BACB Code of Conduct for Behavior Analysts and Registered Behavior Technicians.

 

Scheduling

3. Staff will contact family to communicate session time changes and cancellations.

4. Staff will follow the Wellness policy at all times to prevent the spread of illness.

5. Staff will make every effort to make up treatment hours whenever applicable.

 

Professionalism

6. Staff will respect personal, professional, and cultural boundaries of all clients and families and at all times.

7. We have a zero-tolerance policy for discrimination or harassment at MASS Services LLC. This includes but is not limited to discrimination against one's age, gender, pregnancy, abilities, sexual orientation, religion, nationality, race, and ethnicity.

 

Communication

8. Staff will maintain an open line of communication, by returning all emails, phone calls and text messages within 24 business hours for urgent matters and 48 hours for non-urgent matters.

9. In the interest of client privacy, all clinical staff are prohibited from soliciting and sharing testimonials from current clients. However, MASS Services LLC values feedback from families and will conduct Consumer Experience surveys with parents as a Quality Assurance measure periodically throughout the treatment relationship. Feedback statements will not be utilized on any social media platform without expressed written consent from the parent.

 

Mandated Reporting

10. All MASS Services LLC staff are mandated to report abuse or suspected abuse. If we have reason to suspect that a client or other minor is being abused, we are required to report this (and any additional information upon request) to the appropriate state agency. If we believe that a client is threatening serious harm to him/herself or others, we are required to take protective actions, which could include notifying an intended victim, a minor's parents, or others who could provide protection, or seeking appropriate hospitalization.

Grievances - Parent Concerns Regarding Professional Practices

MASS Services LLC wholeheartedly supports any consumer who comes forward with any claim of inappropriate or unacceptable professional practices. Grievance information will be provided upon request.

To report a Professional or Ethical Concern that has not been resolved by your Clinical Supervisor or Behavior Analyst, please contact our internal Ethics Officer as follows:

 

Jasemine Lakey

(909) 921 - 1404

 

During your call our Ethics Officer will document all information provided, perform a full investigation of the concerns brought forth, and develop a clear and executable action plan to remedy the issue(s Once the investigation is complete, the Ethics Officer will share the resolution plan with the family.

 

Parents may also report any concerns that have not been resolved by any member of our team directly to their child's Insurance Company by filing a formal grievance. Any conflicts are resolved in the best interest of the patient regardless of other stakeholder interests such as third-party insurance companies. Once a grievance is filed, your insurance company will document the incident and contact MASS Services LLC regarding your concerns, along with instructions for remitting a plan of corrective action. Please note, retaliation for the submission of any parent complaint or grievance, whether internally or externally, is unlawful and will not be tolerated at MASS Services LLC.

SERVICE DELIVERY MODEL

 

Social Skills Training

 

Should your child be eligible* to participate in our Social Skills Training, the following information will apply. A release of liability will be included, and must be reviewed and signed by a legal parent or guardian. Failure to complete the required forms by the deadline provided may result in your child not being eligible to attend.

*Client eligibility must be determined by completion of a formalized Social Skills Assessment.

CLIENT PRIVACY, CONFIDENTIALITY + RELEASE OF INFORMATION

 

Notice of Privacy Practices

This notice describes how protected health information about a client may be used and disclosed and how the client can gain access to this information. Please review it carefully.

 

Health Insurance Portability and Accountability Act (HIPAA)

MASS Services LLC collects private and/or potentially sensitive medical information about each client and/or the client's family. This notice explains the client's privacy rights and addresses how MASS Services LLC may use and disclose protected health information. MASS Services LLC does not use or disclose protected health information unless permitted or required to do so by law. MASS Services LLC must adhere to laws aimed at securing the privacy of the client's protected health information. These laws are known as the Health Insurance Portability and Accountability Act (HIPAA) privacy rules. When we do use or disclose protected health information, we will make every reasonable effort to limit its use or the level of disclosure to the minimum we deem necessary to accomplish the intended purpose. Please note that the privacy provisions articulated in this notice do not apply to health information that does not identify the client.

 

Protect Health Information

Protected health information is information about the client relating to a past, present, or future mental health condition, treatment, or payment for treatment that can be used to identify the client. This includes any information, whether oral or recorded in any form, that is created or received by MASS Services LLC. This also includes electronic information and information in any other form or medium that may enable another party to identify the client. Examples of information that can identify a client include, but are not limited to the following:

→ Client’s First and Last Name
→ Telephone Number
→ Address
→ Date of Birth
→ Social Security Number
→ Service Start/End Date
→ Diagnosis

Permitted Uses And Disclosures Of Health Care Information

We may use or disclose the client's health information without the client's permission in the following circumstances, subject to all applicable legal requirements and limitations:

 

Required By Law

MASS Services LLC must make any disclosures required by federal, state, or local law. These may include, but are not limited to, disclosures pertaining to: the reporting of abuse or neglect; court orders, subpoenas, warrants, or other lawful processes; identification/location of a suspect, fugitive, witness, missing person, or crime victim; crime on our work premises; or a serious, imminent threat. Employees of MASS Services LLC are designated as Mandated Reporters.

 

Public Health Risks

We may make disclosures for public health reasons in order to prevent or control disease, injury, or disability; or to report births, deaths, disease or condition, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.

 

Health Oversight Activities

We may disclose protected health information to agencies authorized to receive reports for health oversight activities for audits, investigations, inspections, licensing purposes, or as necessary for certain government agencies to monitor the health care system, government programs, and compliance with civil rights laws.

 

Lawsuits, Disputes, or Other Legal Proceedings

We may make disclosures in response to a subpoena or court or administrative order, if the client is involved in a lawsuit or dispute, or in response to a court order, subpoena, warrant, summons or similar process, or if requested to do so by law enforcement.

 

Serious Threat to Health or Safety; Disaster Relief

We may disclose information to appropriate individual(s)/organization(s) when necessary (a) to prevent a serious threat to the client's health and safety or that of the public or another person, or (b) to notify the client's family members or persons responsible for the client in the course of a disaster relief effort. We will disclose protected health information only to persons we believe to be able to lessen/prevent the threat and will limit the disclosure to that which we deem necessary to lessen or prevent the threat.

The client has certain rights regarding his/her health information, which are listed below. In each of these cases, if the client wants to exercise his/her rights, the client must do so in writing via email to intake@masssvcs.com

→ Right to Inspect and Copy
→ Right to Amend
→ Right to an Accounting of Disclosures
→ Right to Request Restrictions
→ Right to Request Confidential Communications
→ Right to a Paper Copy of This Notice

 

If the client or client's guardian believes that his/her privacy rights have been violated, contact:

Office of Civil Rights, Medical Privacy Complaint Division U.S. Department of Health and Human Services

200 Independence Avenue, S.W. HHH Building, Room 509H Washington, D.C. 20201

Phone: (866) OCR-PRIV (627-7748) TTY: (886) 788-4989 www.hhs.gov/ocr

The client will not be penalized for filing a complaint and the client will continue to have the same access to services with MASS Services LLC

 

Acknowledgment and Receipt:

I acknowledge that I have received a copy of MASS Services LLC's Notice of Privacy Practices. I further acknowledge that I have reviewed and understand the information presented in this notice, including the appropriate contact information for the part(ies) that I should contact in the event that I have any further questions, concerns, requests, or complaints regarding any of the subject matter herein. 

I give permission for MASS Services LLC to collect the following images of my child and/or myself during the time that my child is enrolled in services.

I understand that my child's images may be used for any of the following purposes (please check to indicate consent for each):

• For internal communications between the clinical team and the family
• For internal promotional or marketing materials
• For external promotional or marketing materials
• For educational training presentations
• None

Expiration Date: yearly updated

This release will remain in effect for one year unless otherwise stipulated or revoked in writing by sending an email to intake@masssvcs.com. This agreement can be rescinded at any time without penalty. All permissions outlined herein will be rescinded immediately upon receipt of the parent's written revocation.

 

I authorize MASS Services LLC to keep my signature on file and to charge the credit card selected below for the following:

 

Payment Type:

 

Credit Card Type:

• Visa
• Mastercard
• Discover
• Amex

I understand that I will receive an invoice via email for all copays and coinsurance charges as designated by my insurance plan. I understand that I am responsible for communicating any insurance changes that may impact my copay or coinsurance amount to the MASS Services LLC Finance Department intake@masssvsc.com prior to my card being charged. I understand that failure to pay may result in delay, interruption, or termination of services.

 

I understand that my express consent is required to release any healthcare information relating to assessment and treatement. I, {parentguardianPrinted}, hereby give my consent for MASS Services LLC to release medical and other relevant information to our insurance carrier as required by my/our insurance carrier to process medical billings. 

Liability Waiver

 

I hereby certify that my child(ren) is/are in good physical condition and do/does not suffer from any disability that prevents or limits his/her participation in all activities conducted by undefined. I acknowledge that MASS Services LLC will not assume any responsibility or liability for personal injury or damages caused by the injury. In the event that MASS Services LLC is unable to reach the parent, guardian, or any emergency contact, I hereby give permission for my child(ren) to be transported to the nearest hospital for treatment in case of an accident or emergency. I hereby further authorize MASS Services LLC and its employees to provide for, approve and authorize health care at a hospital if necessary.

PHOTO/VIDEO RELEASE

 

I hereby grant and authorize MASS Services LLC the right to take, edit, copy, publish, distribute, and make use of any and all pictures or videos taken of my child(ren) to be used in and/or for legally promotional materials and digital communications via the Company’s Parent Communication App. This authorization shall continue indefinitely unless I otherwise revoke said authorization in writing. I understand and agree that these materials shall become the property of and will not be returned.

• I understand that I am entitled to a tour of my Treatment Center of choice prior to enrolling my child in Center-Based services.
• I understand that I will be required to attend a Parent Orientation with a Treatment Center Program Manager prior to the onset of Center- Based services.
• I understand that to protect the confidentiality of other Treatment Center clients, parents, guardians, or other family members will not be permitted to observe clinical sessions without the expressed written permission of the Clinical Management Team.
• I understand that MASS Services LLC uses cloud-based apps (i.e., Gmail, Adobe, Rethink, DocHub, etc to record data, request signatures, store information, and communicate with guardians. I give my consent to receive communication regarding my child, his/her services, and special announcements via any platforms that MASS Services LLC chooses to use to convey information that is pertinent to my child's program.
• I understand that children who receive Center-Based services may participate in snack and meal times and that it is my responsibility to keep MASS Services LLC informed, in writing, of all diet and medication changes. In addition, I understand that if I would prefer to opt out of snack and meal times, I may send food items from home for my child to consume during structured meal times. I understand that MASS Services LLC staff members are not authorized to store or administer any medications in the Treatment Center and that if my child requires scheduled medications during his/her sessions, I have the option to appoint myself or an authorized party to conduct a visit to administer medication(s) during therapy sessions or I may choose to receive services in my home.
• I understand that MASS Services LLC celebrates special occasions (i.e., birthdays and holidays) and that I may choose to opt out of allowing my child to participate in any special occasion at any time by communicating my preferences with the clinical team in writing.
• I understand that MASS Services LLC will provide coverage for Provider Cancellations for all clients receiving services in our Treatment Center and that in rare cases, I may not be informed of sudden staffing changes until I arrive to drop off my child.
• I understand that MASS Services LLC is required to host fire drills at least quarterly and that my child will be required to participate in all portions of the drill, which may include evacuating the building.
• I understand that my participation in Parent Coaching is vital for communication with the clinical team as well as generalization across home- center settings. I further understand that refusal to participate in Parent Coaching or respond to correspondence from my child's clinical team may result in dismissal from Center-Based services and transition to my home.
• I understand that my child's treatment session may be observed by MASS Services LLC staff members not on my clinical team for training and/or quality purposes.
• I understand that my child's continued enrollment in Center-Based Services is contingent on a number of clinical, safety, and social factors and that MASS Services LLC reserves the right to recommend discontinuation of my child's Center-Based services and transition to Home- Based services at any time based on these factors.

I HAVE CAREFULLY READ THIS LIABILITY WAIVER AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT BY SIGNING THIS

WAIVER, I AM WAIVING CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE THE RELEASES. I SIGN THIS WAIVER VOLUNTARILY

For non-clinical questions and concerns related to our Treatment Center, please contact Jasemine Lakey, Clinical Director at jlakey@masssvcs.com.

 

Acknowledgedment:

Child Information

Parent Information

Goals for Social Skills Development

Current Skills and Behaviors

Previous Services and Support

Health and Safety Information

Family and Social Environment

Additional Information