INFORMED CONSENT FOR APPLIED BEHAVIOR ANALYSIS (ABA) THERAPY

Satyaluna LLC dba Satyaluna Health & Wellness (SHW) provides Applied Behavior Analysis (ABA) services delivered by licensed and/or credentialed professionals, or by supervised individuals working under licensed professionals. All services comply with the Behavior Analyst Certification Board (BACB) guidelines.

SERVICE STRUCTURE AND SCHEDULING

Session times are scheduled in specific blocks of 2, 3, or 4 hours. Any modifications to scheduled session times must be discussed and approved by your Licensed Behavior Analyst in advance of the scheduled appointment. For all services provided outside our clinic setting, a responsible adult (age 18 or older) must be present throughout the entire session. If no adult is present, our staff will wait outside for 15 minutes and attempt to make contact. If no response is received, staff will leave and a no-show fee will be charged.

STAFFING MODEL AND SUPERVISION

Each case is assigned a minimum of two Registered Behavior Technicians (RBTs) to promote skill generalization and ensure consistent service delivery. This model is essential for therapeutic success as it helps clients apply learned skills across different people and situations. Our agency may require new staff members to shadow current cases as part of training or case transitions. Families must discuss any concerns about shadowing with their supervisor, who will determine if shadowing would be detrimental to the client. We reserve the right to make staffing changes when necessary, with as much advance notice as possible. Alternate staff members may be assigned to cases to promote skill generalization. Declining alternate coverage on the day of service will result in a same-day cancellation fee.
Program supervision is a required component of all direct ABA services. A Board Certified Behavior Analyst (BCBA) will conduct both direct observations with the client and indirect services such as data analysis, staff supervision, and report writing. Direct supervision is an ethical requirement for ABA services, and we cannot provide services without this component. Families are encouraged to discuss any concerns regarding service delivery with their supervisor first. If concerns remain unresolved or involve the supervisor, please refer to the grievance policy.

CANCELLATION POLICY

We require 24-hour advance notice for all cancellations. Sessions cancelled with less than 24 hours' notice or missed without notification will be charged at the full session rate. If you arrive late to your scheduled appointment, the session may be shortened, but you will be charged for the full scheduled time. Please note that a pattern of repeated missed appointments may result in the termination of services.

FINANCIAL AGREEMENTS

Pre-authorization may be required by your insurance provider before beginning ABA services. For clients utilizing in-network services, all co-pays and deductibles are due at the time of service, and we will file claims directly with your insurance provider. For out-of-network services, payment is required at the time of service,
and we will provide documentation for you to submit for insurance reimbursement. Reimbursement rates vary by insurance plan. It is the guardian's responsibility to notify us of any insurance policy changes as soon as possible. Services delivered outside authorization periods or billed to expired insurance policies become the guardian's financial responsibility.

SERVICE RATES

Our standard service rates, which may vary based on insurance contracts, are as follows: Board Certified Behavior Analyst (BCBA) services are billed at $150 per hour, Registered Behavior Technician (RBT) services at $110 per hour, and Therapy Material Fees at $30 per hour. Please refer to the Parent Handbook for current cancellation fees and related charges.

PAYMENT TERM

Co-pays and deductibles are due at the time of service. For your convenience, we accept various forms of payment including major credit cards, debit cards, cash, and checks. Returned checks will incur a $35 fee. Overdue balances are subject to a 10% weekly late fee. In the event that an account becomes delinquent and is referred to collections, the client or responsible party will be liable for all collection costs. Monthly statements for co-pays and deductibles are sent via email and can be paid through the provided payment link.

ELECTRONIC INVOICE CONSENT

By initialing below, I consent to receive invoices and payment notifications via text message and email. I understand I can opt out of text notifications at any time by notifying the billing department in writing. Please indicate your preferences:

COMMUNICATION

In emergency situations, clients should contact 911 or their local emergency services. For non-emergency matters, we will respond to communications within 24 hours. Electronic communication, including email and text messaging, should be used solely for scheduling purposes. To maintain professional boundaries and protect privacy, our staff does not connect with clients or their families on social media platforms.

CONFIDENTIALITY

We maintain strict confidentiality of all client information. However, there are specific circumstances where we are required to break confidentiality: suspected past, current, or possible future child abuse/neglect; suspected viewing of child pornography; suspected elder/dependent adult abuse/neglect; danger to self or others; insurance company requirements; court orders; collection proceedings; and professional consultation with treatment team members.

Satyaluna Health & Wellness utilizes video recording as an integral component of our Applied BehaviorAnalysis services. This documentation serves multiple clinical purposes and maintains our commitment toservice excellence.

1. Clinical Supervision and Quality Assurance Recording of therapy sessions facilitates clinical oversight,enables supervision of treatment implementation, and ensures adherence to established protocols. This supervision is essential for maintaining the highest standards of care and promoting optimal client outcomes.
2. Treatment Documentation and Assessment Video documentation allows for precise measurement ofbehavioral baselines, systematic tracking of progress, and comprehensive assessment of skill acquisition.These recordings support data-driven decision-making and treatment plan modifications.
3. Treatment Program Development Recordings assist in the ongoing refinement and redesign of treatmentprograms, ensuring interventions remain optimally effective and responsive to client needs.
4. Clinical Training and Development Recordings support the training of behavior specialists for both theclient and other children receiving services. This includes:

• Training Registered Behavior Technicians (RBTs)
• Implementing video modeling techniques for client instruction
• Supporting skill development across the clinical team

All video documentation is managed in accordance with HIPAA regulations and healthcare privacy standards. Recordings are maintained on secure, HIPAA-compliant servers with encryption protocols. Access is strictly limited to authorized clinical personnel directly involved in the client's treatment program. Records are retained in accordance with state and federal guidelines, after which they are permanently deleted through secure methods.

Video recording is prohibited in private areas including restrooms and changing facilities. Clinical staff will provide clear notification when recording is initiated, and recording may be suspended upon request during any session.

ASSESSMENT AND TREATMENT

Our treatment process begins with a comprehensive initial assessment to identify behavior functions. Based on this assessment, we develop individualized treatment plans addressing both behavior reduction and skill acquisition goals. All programming decisions are guided by ongoing data collection. Parent and caregiver training is an integral component of our service delivery. We provide regular progress reports, and treatment duration varies based on individual needs and insurance authorization.

PARENT TRAINING

Parent training services are available to provide specific and targeted assistance with behavioral management. These services may be conducted in our office or at your home, based on clinical recommendation. Home-based sessions require a minimum duration of 2 hours. Insurance coverage for parent training varies based on diagnosis and plan eligibility. Please contact our office to verify coverage for these services.

PARENT HANDBOOK ACKNOWLEDGMENT AND AGREEMENT

I hereby acknowledge receipt of the Parent Handbook ("Handbook"), which provides comprehensive information regarding Applied Behavior Analysis (ABA) Therapy services. The Handbook includes detailed information about ABA Therapy benefits and implementation, parent/caregiver roles and responsibilities, program expectations, data collection and progress monitoring procedures, safety protocols, emergency procedures, illness and attendance policies, caregiver training requirements and opportunities, communication procedures, documentation requirements, client rights and responsibilities, and complaint and grievance procedures.

By signing this document, I confirm that I have received, thoroughly reviewed, and understand the contents of the Parent Handbook. I hereby agree to comply with all policies, procedures, and guidelines outlined in both this consent form and the Parent Handbook. I understand and acknowledge that the Parent Handbook constitutes an integral part of this agreement and is incorporated herein by reference. Furthermore, I acknowledge that non- compliance with any policies or procedures contained within either this agreement or the Parent Handbook may constitute grounds for service termination.

HANDBOOK UPDATES

I understand that the Parent Handbook may be updated periodically, and I will be notified of any significant changes. I agree to review and comply with any updates or modifications to the handbook as they are implemented.

TREATMENT DURATION AND INTENSITY

ABA services are typically authorized in 6-month periods, though this may vary by insurance provider. We recommend scheduling all authorized hours, as failure to do so may impact future authorization requests. Progress reports will be provided to both family and funding sources with recommendations for continuing, reducing, or increasing service hours.

TERMINATION OF SERVICES

Services may be terminated for various reasons, including but not limited to: achievement of treatment goals, lack of progress, repeated missed appointments, non-payment of fees, or loss of insurance authorization. We will provide appropriate referrals and transition support when services are terminated.

ACKNOWLEDGMENT

By signing below, I acknowledge that I have received and agree to the terms in both this consent form and the Parent Handbook:

• I have received the Parent Handbook
• I have read and understand all policies and procedures
• I agree to comply with all requirements outlined in both documents