The Perfect Child Intake Packet

Dear Parents/Guardians,

Welcome to The Perfect Child! We are grateful that you are interested in our program and look forward to meeting you and your family. The Perfect Child is a school-based and home-based ABA (Applied Behavior Analysis) program that provides one-on-one therapy for children diagnosed with Autism, as well as other Autism Spectrum Disorders. TPC looks to provide a quality and caring service to each child that is enrolled. Each staff member is highly trained and dedicated to meet the needs of the families and children they serve.

The first step in enrolling in our program is completing the necessary paperwork for your child. Please thoroughly fill out each page of the client application packet that is provided below. Once you have completed the forms you can hit the continue button and sign at the bottom of this form. In addition to the application packet, attach all medical documentation relating to the autism diagnosis (this must include Neuropsychological Evaluation) and a copy of your child's insurance card. We will be in contact with you when we receive the application packet to continue the intake process. If you have any questions along the way, please contact us.

Thanks again for your interest in our program!
Today's Date*

MonthDayYear
Date
Client Legal Name*

First NameMiddle NameLast Name
Client Legal Name - Hidden
Name Client goes by*
Date of Birth*

MonthDayYear
Date of Birth
Gender
Primary Language*
Home Address*
City*
State*
Zip*
Name of School*
FAMILY INFORMATION
Client lives with*
Parent/Guardian 1
Name Parent/Guardian 1*
Name Parent/Guardian 1 - Hidden
Relationship*
Home Address*
City*
State*
Zip*
Home Phone*
Cell Phone*
E-mail Address*
example@example.com
Employed by*
Occupation*
Employer Address*
Employer Phone*
Parent/Guardian 2
Name Parent/Guardian 2
Relationship
Home Address
City
State
Zip
Home Phone
Cell Phone
E-mail Address
example@example.com
Employed by
Occupation
Employer Address
Employer Phone
EMERGENCY CONTACT INFORMATION
I give permission to The Perfect Child to take whatever emergency decisions are judged necessary for the care and protection of my child while at the place of service.

Please provide the name and phone number of individuals who can be called in case of an emergency when parents/guardians are not available.
Emergency Contact*
Relationship*
Home Phone Number*
Cell Phone Number*
INSURANCE INFORMATION
I understand that in some medical situations, the staff will need to contact local emergency resources before the parent/guardian, child's physician and or other adult acting on the parent/guardian's behalf.
Name of Primary Insurance (Private or MA)*
Member Number/MA Number*
Group Number*
Subscriber Name*
Address of Policyholder*
City*
State*
Zip*
Phone Number of Policyholder:*
Name of Secondary Insurance (If Primary insurance is private)
Member Number/MA Number
Group Number
Subscriber Name
Address of Policyholder
City
State
Zip
Phone Number of Policyholder:
I prefer:*

Pay my balance in full at time of servicePay my balance in full upon receipt of first statementMake payment arrangements prior to services being rendered
ASSIGNMENT OF INSURANCE BENEFITS
I understand the confidentially of my records as protected by law. Information about me/my child cannot be released without my consent. I understand I may revoke this consent at any time.

I hereby give authorization for The Perfect Child to contact and inform my primary and secondary (if applicable) insurance companies of all medical information included in treatment plans relating to all claims for benefits submitted on behalf of myself and/or dependents. I further expressively agree and acknowledge that my signature on this documents authorizes my physician to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and every claim to be submitted for myself and/or dependents, and that I will be bound by this signature as though the undersigned had personally signed the particular claim. I authorize the Insurance Companies named above to pay and hereby assign directly to TPC all benefits, if any, otherwise payable to me for his/her services. I understand I am financially responsible for all charges incurred. I further acknowledge that any insurance benefits, when received and paid to TPC will be credited to my account, in accordance with the above assignment.
Authorized signature of Subscriber*

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Date*

MonthDayYear
Date
MEDICAL INFORMATION
Hospital/Clinic Preference
Client's Primary Doctor*
Doctor Phone Number*
Do we have permission to contact the Doctor?*
Allergies*
List any medication routinely taken at home*
List any medical restrictions to client's activities*
ADDITIONAL SERVICE PROVIDERS
Social Worker
Social Worker Phone Number
Interpreter
Interpreter Phone Number
School
Grade
Teacher's Name
Teacher's Phone Number
OTHER PROVIDERS (IF APPLICABLE)
Name
Type of Service
Phone Number
Name
Type of Service
Phone Number
THERAPY OPTIONS
TPC offers both in-home and school-based therapy for clients enrolled in our program. Please complete the form below to indicate which therapy you prefer for your child. The information you provide will help us to determine the type of therapy you are seeking for your child.

NOTE: Your insurance or your state may not allow school-based services.
I am interested in:*

IN-HOME SERVICESIN-SCHOOL SERVICES
Is there a program you would not prefer or unable to participate in?*

YESNO
If YES, please explain
Strengths: Please list all of your child’s strengths such as drawing, writing, computer, etc.*
Main Concerns

Please list any concerns the child may have at home or in the community. This may include, but not limited to, sensitivity (i.e. oversensitive to noises, oversensitive to certain material or texture of food), behaviors communication, social skills and play skills. Additionally, provide any special accommodations that would help staffs to better support the child's progress.
Possible Reinforcers

Please list all or any preferences that your child has shown and put * next to the ones that are highly preferred in each category. Be SPECIFIC as possible!!
Food: (snacks, candies, chocolate - please be specific; kind or brand names)*

0/275
Toys: (games, stuff animals, etc.) *

0/275
Activities (reading books, listen to music, etc.)*

0/275
Other (any special preferences not mentioned)*

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Anticipated Schedule (Please indicate start/end time, AM/PM) *

	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Start / End Times

SERVICE COORDINATION
Child's Name*
Date*

MonthDayYear
Date

Service

	# Of Hours	Frequency
Special Education Services
Child Welfare- Targeted Case Management (CW-TCM)
Community Alternatives for Disabled Individuals (CADI) Waiver
Personal Care Assistant (PCA)
Mental Health- Targeted Case Management (MH-TCM)
Recreational Therapy
Psychiatrist
Physical Therapy
Speech Therapy
Occupational Therapy
Collaborative/Wraparound Services
Family Psychotherapy Services
Other (explain)

Upload Diagnoses Documentation Here

Cancelof
RELEASE OF CONSENT
Client Name*
*A separate Consent for Exchange of Information form must be completed for each individual or agency you wish for TPC to communicate with.*
- I understand that my records are protected by data practice laws and cannot be released without my consent unless otherwise allowed by law.
- I understand that only the information and records indicated below will be released or obtained.
- I understand that this consent does not authorize the recipient of the information or records to re-disclose the information or records to any other person or facility unless authorized by law.
- I understand that the information will only be used for the purposes indicated below.
- I understand that I may withdraw or modify this consent at any time but, that the revocation or modification will not affect any release of information that previously occurred.
- I understand that the observation and/or assessment can take place in either setting.
I authorize The Perfect Child ABA*
To obtain records from or release records to:
Name of Agency
Name of Staff
Type of information released:

Assessments or evaluationsEducational recordsBehavior reportsMedical recordsAllOther
Information may be shared in person or by mail. I also give permission to share information using the following methods:

PhoneEmailFaxAllOther
Parent or Guardian or Authorized Representatives Signature*

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Date*

MonthDayYear
Date
Federal Law: "This information has been disclosed to you from records whose confidentiality is protected by Federal Law prohibits disclosing this material. Federal regulations (42 CFR Part 2) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose."
THE PERFECT CHILD CONSENT FORM
I, {name26} as parent/legal guardian of {clientLegal}, give permission for my child/ward, (hereinafter "Client") to participate in the The Perfect Child ABA services. I have received an enrollment application package and have read, understood and completed all the necessary forms required prior to enrollment. I agree with the current personal development goals established for Client, and I am aware that I will be required to attend periodic meetings for review and revision of Client's individual program. I also understand that I may withdraw Client at any time. I understand that TPC reserves the right to terminate the enrollment of Client for failure to adhere to program standards.

I have given all emergency contact information to TPC.

I also give permission for TPC to use any necessary information and data collected on Client to be reviewed and used in presentations at any professional meetings and conferences. I understand that Client's name and identity will be kept confidential and will not be disclosed without prior written notification. I also understand that this will serve to further the advances in the field of autism.

I hereby agree to hold harmless and release from any and all liability, The Perfect Child, its directors, officers, employees, agents, affiliates, sponsors, and promoters, as well as, their respective directors, officers, employees, and agents (hereinafter collectively known as "TPC"), for any injury or illness to the Client, arising out of or in connection with his/her participation in TPC. Also, to the fullest extent allowed by law, I hereby waive and discharge my and the Client's rights, including those of our heirs and assigns, to any and all claims of damages for injury or illness to the Client, against TPC. I agree that health insurance coverage for the Client is my sole responsibility.
Parent/Guardian comments*

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Parent or Legal Guardian Name *
Date*

MonthDayYear
Date
Parent or Legal Guardian Signature*

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Date*

MonthDayYear
Date
CLIENT NOTIFICATION OF PRIVACY RIGHTS
Health Insurance Portability and Accountability Act (HIPAA)

Recent federal law, the Health Insurance Portability and Accountability Act (HIPAA), has created new client protections surrounding the use of protected health information. Commonly referred to as the "medical records privacy law," HIPAA provides client protections related to electronic transmission of data, the keeping and use of client records, and the storage and access to health care records. HIPAA applies to all health care providers, including mental health care, and providers and health care agencies throughout the country are now required to provide clients a notification of their privacy rights as it relates to their health care records. You may have already received similar notices such as this one from your other health care providers.

As you might expect, the HIPAA law and regulations are extremely detailed and difficult to grasp if you don't have formal legal training. This Client Notification of Privacy Rights is designed to inform you of your rights in a simple yet comprehensive fashion. Please read this document, as it is important you know what client protections HIPAA affords all of us. In mental health care, confidentiality and privacy are central to the success of the therapeutic relationship and as such, you will find we will do all we can do to protect the privacy of your mental health records.

HIPAA requires that we secure your signature indicating you have received or been offered the Client Notification of Privacy Rights document.

You can access the Client's HIPAA Notice of Privacy Practices here
I have accepted a copy of the Client Notification of Privacy Rights documentI have been offered a copy of the document and do not wish to have a copy at this time
(I understand I have the right to review the document before signing this acknowledgement form.)
Client's Name*
Client or Legal Guardian Signature*

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Client Date of Birth*

MonthDayYear
Date
Date Signed*

MonthDayYear
Date
You may retain the notification document for you records.
ADDITIONAL INFORMATION
Thank you for completing the client registration packet. In addition to submitting the application packet, please include the following items when applying for enrollment:
- Copy of your child's insurance card(s)
- Medical documentation pertaining to the diagnosis of autism
- Reports from other service providers (if applicable)
  o Speech therapy, school services, occupational therapy, etc.
Please contact the agency if you have any questions when completing the application packet, or regarding the intake process.

Thanks again,

Intake Coordinator

The Perfect Child

Tel:888-320-3222

Fax: 347-212-1565

CR@TPCABA.COM
How did you hear about us?*

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Please Acknowledge -

Insurance companies may send payments from time to time to clients directly as opposed to the provider. In this event, you will be required to mail the checks with their EOB/EOP (Explanation of Benefits/Explanation of Payments) to 1255 E 31st street, Brooklyn NY 11210.

There may be a case when we may need to file appeals on your behalf for an insurance company to approve services or approve payment. Please acknowledge that you will work together with us on this task.

There may be a case where you will need to fill out a coordination of benefits form with your insurance company. Please acknowledge that you will do so.

Your signature below acknowledges the three paragraphs above.
Parent or Legal Guardian Signature*

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Date*

MonthDayYear
Date
Should be Empty:

FAMILY INFORMATION

Parent/Guardian 1

Parent/Guardian 2

EMERGENCY CONTACT INFORMATION

INSURANCE INFORMATION

ASSIGNMENT OF INSURANCE BENEFITS

MEDICAL INFORMATION

ADDITIONAL SERVICE PROVIDERS

OTHER PROVIDERS (IF APPLICABLE)

THERAPY OPTIONS

SERVICE COORDINATION

RELEASE OF CONSENT

THE PERFECT CHILD CONSENT FORM

CLIENT NOTIFICATION OF PRIVACY RIGHTS

ADDITIONAL INFORMATION