1. ABA Intake Packet 2025 Version 3.2

ABA Intake Packet
4980 Hillsdale Circle Suite B, El Dorado Hills, CA 95762

384 Placerville Drive Suite C, Placerville, CA 95667

9083 Foothills Boulevard Suite 350, Roseville, CA 95747

2721 Citrus Road Suite B, Rancho Cordova, CA 95742

900 Fortress Street Suite 200, Chico, CA 95928

(916) 693.6469
Thank you for choosing us at ABLE Kids Co. to help you meet the individualized goals for your child or children. We are passionate about the ABA world and our hearts are filled in seeing such amazing growth in the children and families we support. That is why we are here.

The attached packet of information will help inform you about our policies and procedures.

Again, Thank you for the trust that you are placing in us. We understand that some of these forms may be challenging, time consuming, and in places redundant. However, the more information that we have the better able we will be to assist you and your family proactively while we develop their program.

If at any time in this process you have any questions, please contact us.
Requirements to Begin ABA Services include:
Completed Intake Packet
- Intake Form
- HIPAA Form
- Client Insurance Information (including diagnostic evaluation/medical referral for ABA and copies of medical cards)
- Authorization to Release Information
- Informed Consent
- Authorization for Assignment of Benefits and Signature on File Service
- Agreement and Consent Form
- Health Records and Information (Optional- as needed)
- Consent to security camera video and audio recording in clinic (required)
- Permission for staff to Videotape and Photograph (Optional)
Documents Required For Authorization Request:
Diagnostic Evaluation or Medical Referral for ABA*

Cancelof
Medical Card - Front (Primary)*

Cancelof
Medical Card - Back (Primary)*

Cancelof
Medical Card - Front (Secondary, if applicable)

Cancelof
Medical Card - Back (Secondary, if applicable)

Cancelof
Consent to Video and Audio Recording in the Clinic
For the safety and supervision of all patients, caregivers, and staff, our clinic utilizes video and audio recording throughout the facility. These recordings help ensure a secure and high-quality environment for everyone. Please be assured that all recordings are kept strictly private, are not shared externally, and are handled in full compliance with HIPAA guidelines to protect your privacy and confidentiality. In order for any services to be provided within the clinic setting, caregiver(s) must consent to this recording policy as part of our commitment to maintaining a safe and professional space.
I, Caregiver First Name* Caregiver Last Name* consent to the clinic video and audio recording as stated above.
Caregiver Signature:*

Clear
Information Related to Scheduling and Sessions
Every child has a Supervising BCBA designated as the Team Leader for your family.

If the program is authorized as a "3-Tiered" support system your child will have a "mid-level" who works directly under the BCBA as an assistant. As well as Behavior Technicians who directly implement the programming. All Mid-Levels have a BCaBA OR Master's Degree OR are enrolled in a BCBA program. If your insurance authorizes a "2-Tiered" support system then you will have a BCBA and Behavior Technician(s). Almost all technicians are certified as "Registered Behavior Technicians" by the Behavior Analyst Certification Board.

Sessions for ABA are usually scheduled in 2-6 hour blocks. The research shows that longer sessions result in greater retention of skills and it makes scheduling more convenient for all parties. If this is not convenient for your family, please bring this up during the initial intake meeting.

For in home sessions, a parent/legal guardian/responsible adult is required to be present and available in home throughout the entire therapy session(s).

We request that families give us at least two weeks’ notice on significant changes in their plans for ABA session scheduling in order to facilitate consistency in service delivery.

The standard of care outlined in the Behavior Analyst Certification Board Guidelines for Autism includes ongoing supervision of technicians, program consultation to parent/guardians, program review, and program revision as services performed by a BCBA. Clinical management and case supervision for the general standard of care is 1 hour of supervision for every 5 hours of direct treatment, this includes 1:1 and Social Groups.

This ratio of clinical management and case supervision hours to direct treatment hours reflects the complexity of ASD based on the assessment conducted by the BCBA and your scoring on the standardized assessment (REQUIRED) and the patient's responsiveness to goals, and data-based decision-making which characterizes ABA treatment. A number of factors increase or decrease clinical hours and case supervision needs on a shorter-term or longer-term basis. These include:
- Treatment dosage/intensity
- Client behavior problems (especially if dangerous or destructive)
- The sophistication or complexity of treatment protocols
- The ecology of the family or community environment
- Lack of progress or increased rate of progress
- Changes in treatment protocols
- Transitions with implications for continuity of care
Intake Questionnaire

Confidential
The following questionnaire is to be completed by the child's parent or legal guardian. This form has been designed to provide essential information before your initial appointment in order to make the most productive and efficient use of our time. Please feel free to add any additional information, which you think, may be helpful in understanding your child.

ABLE Kids will retain all information provided by you. This information is strictly confidential and will only be released in accordance with HIPAA guidelines and as mandated by law.
Identifying Information
Name of person completing this form:*

First NameLast Name
Child's legal first name:*
Child's legal last name:*
Nickname or name child routinely goes by:*
Child's date of birth:*
Child's age:*
Child's race/ethnicity:*
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

List all medical diagnoses:*

	Diagnosis	DSM Code (if known)	Severity Level	Diagnosing Physician	Date of Diagnosis	N/A
Diagnosis 1
Diagnosis 2
Diagnosis 3
Diagnosis 4
Diagnosis 5

Please describe the challenges your child is now having, and what goals you have while your child is with us. *

When is your child available for ABA? Please check all that apply. Please note that we require consistent availability with matching times to ensure staffing.*

	Mornings (9-12)	Mid-days (12-3)	Afternoons (3-6)	Not available this day
Mondays/Wednesdays/Fridays
Tuesdays/Thursdays
Saturdays
Sundays

Family Information
Marital Status:*

MarriedRemarriedDivorcedSeparatedWidowedSingleCohabitants

If divored, please answer the following questions:*

	Type answer
Who has legal custody?
Is it full or joint?
Who has physical custody?
Is it full or joint?
Are there special circumstances we should know about?
Are there any court orders?
Is there restricted communication?

Parent/Guardian Name*

First NameLast Name
Relation to child:*
Date of birth:*
Age:*
Occupation:*
Employer:*
Email:*
example@example.com
Home phone number:*
Please enter a valid phone number.
Parent/Guardian cell phone number:*
Please enter a valid phone number.
Health:*

ExcellentGoodFairPrefer not to say
Type an answer instead:
Parent/Guardian name:*

First NameLast Name
Relation to child:*
Date of birth:*
Age:*
Occupation:*
Employer:*
Email:*
example@example.com
Home phone number:*
Please enter a valid phone number.
Parent/Guardian cell phone number:*
Please enter a valid phone number.
Health:*

ExcellentGoodFairPrefer not to say
Type an answer instead:
Siblings: Please include: Names / Age / Living with? / School / Grade*
Is English your primary language?*

YesNo
If no, will you need interpreter services?

YesNo
If an interpreter is needed, what language?
FAMILY BEHAVIORAL HISTORY

Is there a history in your immediate family of the following:

Conditions:*

	Yes	No
Autism Spectrum Disorders
Learning Problems/Disabilities
ADHD/ADD/Attention Problems
Depression & Manic-Depression
Behavior Problems in School
Anxiety Disorders (OCD, Phobias, etc)
Intellectual Disability
Psychosis/Schizophrenia
Substance Abuse/Dependence
Other Mental Health Concerns

If yes to any of the conditions above, please describe the relationship to your child. *
PRE-NATAL AND DELIVERY HISTORY
Were there any complications during pregnancy?*

YesNo
If Yes, please provide treatment details:*
Was birth at full term?*

YesNo
If no, please provide details:*
Type of Delivery:*

SpontaneousInducedVaginalC-sectionOther
Complications or concerns at birth?*

YesNo
If yes, please provide details including any treatments given and birth weight of your child. *
Is there any additional pre-natal or birth information that might be of assistance to us?*
Previous and Current Services
Has the child you are seeking services for received ABA in the past?*

YesNo

List previous ABA services:*

	Provider Name	Recommended hours per week	Scheduled hours per week	Start date (best estimate)	End date (best estimate)	N/A
Provider 1
Provider 2
Provider 3
Provider 4
Provider 5

What was the reason for stopping services with your most recent provider? *

List other services:*

	Provider Name	Recommended hours per week	Scheduled hours per week	Start date (best estimate)	End date (best estimate)	N/A
Speech Therapy
Occupational Therapy
Physical Therapy
Other (list what service with company name)

Medical History
Does your child have a primary care physician?*

YesNo
Consent to communicate with your child's primary care physician?*

YesNo
If no, reason for refusal:*
Name of child's physician:*
Practice Name:*
Physician's phone number:*
Please enter a valid phone number.
Physician's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does your child have any hearing problems?*

YesNo
Please list date of last hearing test and who performed (pediatrician, school):*
Does your child have any vision problems?*

YesNo
List any operations, serious illnesses, injuries (especially head), hospitalizations, ear infections, or other special conditions your child has had: *
List any medications your child is currently taking or has taken for extended periods (include dosage level and how often taken):*
Does your child have any allergies to medication, food/drinks, and/or other substances?*

YesNo
If so, please list allergies: *
Child's current height: Height* ft. Height* inches
Child's current weight: Weight* lbs
Date of most recent wellness check:*

MonthDayYear
Date
EDUCATION HISTORY
List in chronological order all schools you child has attended: Please include all of the following: School Name / Years of attendance / Grade / Special Ed. or Gen. Ed.*

List in chronological order all schools you child has attended: *

	School name	Year(s) of Attendance	Grade	Educational Setting	Educational Program	N/A
School 1
School 2
School 3
School 4
School 5

Current Times of Attendance:*
Does your child's teacher have concerns about him/her (list):*
What is your child's favorite subject/class/activity?*
What is your child's least favorite subject/class/activity?*

If your child has been in Special Education, did they have any of the following: *

	Yes	No
504 Plan
I.E.P
Psychological Evaluation
Special Evaluation
Behavior Intervention Plan
Physical Therapy Evaluation
Adaptive Technology Evaluation
Occupational Therapy Evaluation
Speech & Language Evaluation

If your child is in Special Education, how are they supported?*

	Yes	No
Special Day Program
Collaborative Education
Pull-Out
Consultation
Resource Classroom
Team Taught Classes
Psycho educational Center
Self-Contained Classroom

DISCIPLINE INFORMATION

Parents may use a wide range of discipline strategies with their children. Listed below are several examples. Please rate how likely you are to use each of the strategies listed:*

	Very Unlikely	Somewhat Likely	Very Likely
Let situation go
Take away a privilege (i.e., no TV)
Assign an additional chore
Take away something material
Send to room
Reason with child
Ground child
Yell at child
Send to time out
Ignore

Intervention Effectiveness: Please list the most effective form of intervention you use. *
Please rate what percentage of discipline is handled by each of the following:
Mother: * %. Father* %
ADDITIONAL INFORMATION
Please list the five things you would like for your child to do more of and less of in order of priority to you.

For example, instead of saying, "I want my child to be more responsible," translate that into actual behaviors such as "I want my child to do household chores, do homework when told, brush their teeth on their own.", etc.
5 things you would like your child to do more often*
3-5 things you would you like your child to do less often*
Do you have safety concerns regarding your child's activities at home/in the community?*

YesNo
If yes, explain safety concerns and locations:*
BEHAVIOR

How many times per day does your child engage in each of the following? Put a 0 if your child does not engage in a listed behavior*

	How many times per day	What does the behavior look like?
Tantrum
Noncompliance
Aggression (towards others)
Self-Injury
Self-Stimulatory behavior
Property destruction
Mouthing items not meant to be mouthed
PICA (eating items not meant to be eaten)
Elopement (running away)
Perseveration
Inappropriate comments (e.g., This is stupid, I hate you)
Cursing

What triggers the behavior:*

	When told "no"	A nonpreferred/ aversive task/demand	When the child is not receiving attention	For sensory input	For no obvious reason	N/A
Tantrum
Noncompliance
Aggression (towards others)
Self-Injury
Self-Stimulatory behavior
Property destruction
Mouthing items not meant to be mouthed
PICA (eating items not meant to be eaten)
Elopement (running away)
Perseveration
Inappropriate comments (e.g., This is stupid, I hate you)
Cursing

Are there any other behavior concerns not listed above? Please describe.
Sensory Issues: Does your child have sensitivity to sound, light, touch or texture? If yes, please explain:*
SPEECH
Do you have concerns regarding your child's speech?*

YesNoOther
If yes, please explain:*
Does your child use a communication system such as PECS, sign, augmentative device (AAC), etc?*

YesNoOther
If yes, which communication system is used/encouraged?*
Speech Comments:
FINE MOTOR SKILLS
With which hand does the child use predominately:*

RightLeftBoth
SLEEP

Do you have any of the following concerns regarding your child's sleep?*

	Yes	No
Difficulty falling asleep
Frequent waking & stays awake
Problem behaviors associated with bedtime
Excessive daytime sleepiness (not associated with a medical condition)
Inadequate nighttime sleep duration

PARENT / FAMILY PRIORITIES & PREFERENCES
Top three areas/goals you would like to see change for your child in next 6 months:*
RAISD
The Reinforcer Assessment for Individuals with Severe Disability (RAISD) is a structured interview with the purpose of obtaining as much specific information from the informant (e.g., teacher, parent, caregiver) as to what they believe would be useful reinforcers for the student.

The purpose of this structured interview is to get as much specific information as possible from the informant (e.g., teacher, parent, or caregiver) as to what they believe would be useful reinforcers for the student. Therefore, this survey asks about various categories of stimuli. After the informant has generated a list of preferred stimuli, ask additional probe questions to get more specific information on the student’s preferences and the stimulus conditions under which the object or activity is most preferred (e.g., What specific TV shows are his favorite? What does she do when she plays with a mirror? Does she prefer to do this alone or with another person?)
Some children really enjoy looking at things such as a mirror, bright lights, shiny objects, spinning objects, TV, etc. What are the things you think your child most likes to watch?*
Some children really enjoy different sounds such as listening to music, car sounds, whistles, beep, sirens, clapping, people singing, etc. What are the things you think your child most likes to listen to?*
Some children really enjoy different smells such as perfume, flowers, coffee, pine trees, etc. What are the things you think your child most like to smell?*
Some children really enjoy certain food or snacks such as ice cream, pizza, juice, graham crackers, McDonald’s hamburgers, etc. What are the things you think your child most likes to eat?*
Some children really enjoy physical play or movement such as being tickled, wrestling, running, dancing, swinging, being pulled on a scooter board, etc. What activities like this do you think your child most enjoys?*
Some children really enjoy touching things of different temperatures, cold things like snow or an ice pack, or warm things like a hand warmer or cup containing hot tea or coffee. What activities like this do you think your child most enjoys?*
Some children really enjoy feeling different sensations such as splashing water in a sink, a massager against the skin, or the feel of air blown on the face from a fan. What activities like this do you think your child most enjoys?*
Some children really enjoy it when others give them attention such as a hug, a pat on the back, clapping, saying “Good Job,” etc. What forms of attention do you think your child most enjoys?*
Some children really enjoy certain toys or objects such as puzzles, toy cars, balloons, comic books, flashlight, bubbles, etc. What are your child’s favorite toys or objects?*
What are some other items or activities that your child really enjoys? or anything that we haven't discussed? *
Is there anything that you don't want us to use as a reinforcer or to place a limit on?*
SUPPORTING BEHAVIORS:

Sometimes when teaching our patients appropriate replacement behaviors, students may become upset or cry. When this happens, we are very adept at working through these instances with favorable outcomes. We want to understand how you feel about this when it happens. (please note that all behavior support plans are discussed with parents and strategies for responding are explained and approved. Providers can debrief parents after any "difficult" sessions as well.)
I am comfortable with letting my child cry and letting providers handle the situation*

YesNoOther
INFORMED CONSENT FOR BEHAVIORAL SERVICES:

I hereby voluntarily apply for and consent to services by ABLE Kids Co. This consent applies to my child named below. Since I have the right to refuse services at any time, I understand and agree that my continued participation implies voluntary informed consent. I understand and agree that my disclosures and communications are considered privileged and confidential except to the extent that I authorize a release of information or under certain other conditions listed below: (1) where abuse or harmful neglect or children, the elderly, or disabled or incompetent individual is known or reasonably suspected (2) where such information is necessary for the company to pursue payment for services rendered (3) where an immediate threat of physical violence against a readily identifiable victim is disclosed to the therapist (4) where the client is examined pursuant to a court order. I hold ABLE Kids harmless for releasing information under the above conditions.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian Name*

First NameLast Name
Child's Name*

First NameLast Name
AUTHORIZATION FOR USE/DISCLOSURE OF HEALTH INFORMATION
Authorization for Use/Disclosure of Information: I voluntarily consent to and authorize my health care provider blanks to use or disclose my child's health information during the term of this Authorization to the recipient(s) that I have identified below.
Recipient: I authorize my child's health care information to be released to the following recipient(s):

Name: ABLE Kids Co.

Address:

4980 Hillsdale Circle Suite B, El Dorado Hills, CA 95762

OR

384 Placerville Drive Suite C, Placerville, CA 95667

OR

9083 Foothills Boulevard Suite 350, Roseville, CA 95747

OR

2721 Citrus Road Suite B, Rancho Cordova, CA 95742

OR

900 Fortress Street Suite 200, Chico, CA 95928

(916) 693.6469
Purpose: I authorize the release of my child's health information for the following specific purpose: (Note: "at the request of the patient" is sufficient if the patient is initiating this Authorization or "continuity of care" for your child if they are not able to authorize permission.
Information to be disclosed: I authorize the release of the following health information: (check the applicable box below)

All of my childs health information that the provider has in his/her possession, including information relating to any medical history, mental or physical condition and treatment received.
(Or)Only the following records or types of health information:
Redisclosure: I understand that my child's health care provider cannot guarantee that the recipient will not redisclose my child's health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.

Refusal to sign/right to revoke: I understand that signing this form is voluntary and that if I don’t sign, it will not affect the commencement, continuation or quality of my treatment at ABLE Kids o. If I change my mind, I understand that I can revoke this authorization by providing a written notice of revocation to the ABLE Kids CO Office of Compliance at the email address listed below. The revocation will be effective immediately upon my health care provider’s receipt of my written notice, except that the revocation will not have any effect on any action taken by my health care provider in reliance on this Authorization before it received my written notice of revocation.

Expiration of Consent: This form is only valid from 12 months of the date of signature. Permission will not exceed the 12th month. In order to obtain new permissions a new form will be given prior to the expiration date (listed below)

Questions: I may contact ABLE Kids Co. for answers to my questions about the privacy of my health information at renee@ablekidsco.com, or by telephone at (916) 693-6469.
Name

First NameLast Name
Signature

Clear
Service Agreement and Consent Form

This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and new client rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operation. HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that we obtain your signature acknowledging that we have provided you with this information. Although these documents are long and sometimes complex, it is very important that you read them carefully and that you ask questions you have about the procedures at any time. When you sign this document, it will also represent an agreement between us. You may revoke this agreement in writing at any time. That revocation will be binding on us unless we have taken action in reliance on it; if there are obligations imposed on us by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred. If you have any questions or concerns, please feel free to discuss them with us.
SERVICES OFFERED
The ABLE Kids Co program provides intensive ABA services for children on the Autism Spectrum and children with other disabilities or behavioral challenges. Our services consist primarily of individual assessments (behavioral evaluations), training, observations, and ABA in-home or clinic based services. Parents are expected to provide the materials as needed for the in-home ABA program. In addition, parents agree to provide an appropriate space (by mutual agreement) for the instruction to occur in the home. They also agree to have an adult 18 years or older present during all sessions. Parents will participate in monthly team meetings to discuss progress and the modifications of techniques as needed. They also agree to implement program goals on a daily basis and to fully participate in the program.

APPOINTMENTS
Except for emergencies, we will see you (or your child) at the time scheduled. We understand that circumstances (such as an illness or family emergency) may arise which necessitate the occasional cancellation of appointments. In these cases, in order to avoid any misunderstanding, we ask that you send a message to scheduling as soon as possible to cancel or reschedule. This will allow us to offer your time to another patient and ensure our staff get the hours they rely on.

CONFIDENTIALITY, RECORDS, AND RELEASE OF INFORMATION
Services are best provided in an atmosphere of trust. Because trust is so important, all services are confidential except to the extent that you provide us with written authorization to release specified information to specific individuals, or under other conditions and as mandated by California and Federal
law and our professional codes of conduct/ethics. These exceptions are discussed below.

TO PROTECT THE CLIENT OR OTHERS FROM HARM
If we have reason to suspect that a minor, elderly, or disabled person 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 the police, and intended victim, a minor’s parents, or others who could provide protection,or seeking appropriate hospitalization.

PROFESSIONAL RECORDS
You should be aware that, pursuant to HIPAA, we keep clients' Protected Health Information in one set of professional records. The Clinical Record includes information about reasons for seeking our professional services; the impact of any current or ongoing problems or concerns; assessment, consultative, or
therapeutic goals; progress towards those goals, a medical, developmental, educational, and social history; treatment history; any treatment records that we receive from other providers; reports of any professional consultations; billing records; releases; and any reports that have been sent to anyone, including statements for your insurance carrier. Personal notes are taken during supervision sessions and by the ABA technicians. While the contents of notes vary from client to client, most are anecdotal notes related to progress and future goals, reference to conversations, and hypotheses of the professional.

PATIENT RIGHTS
HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an
accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper
copy of this Agreement, the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you.

CONTACTING US
Given their many professional commitments, our professionals are often not immediately available by telephone. If you need to leave a message, we will make every effort to return your call promptly (within 24-48 hours with the exception of holidays and weekends.). If you are difficult to reach, please leave
some times when you will be available. Because of the nature of the services we provide, we do not provide on-call coverage 24 hours per day, 7 days a week. In emergency or crisis situations, please contact your physician, or call 911 and/or go to the nearest hospital emergency room.

CONSENT
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 HIPAA notice form described above or have been offered a copy and declined. Consent by all parents/legal guardians (those with legal custody) is required.
Parent/Guardian's Signature*

Clear
Parent/Guardian's Name*

First NameLast Name
Child's Name*

First NameLast Name
HIPAA PRIVACY AUTHORIZATION FORM

Authorization for Use or Disclosure of Protected health Information(Required by the Health Insurance Portability and Accountability Act, C.F.R. Parts 160 and 164)
This medical information may be used by the person I authorize to receive the information for medical treatment or consultation, billing or claims payment or other purposes as I may direct.*

I understandI do not understand
ACKNOWLEGE RECEIPT OF “NOTICE OF PRIVACY PRACTICES”

By signing this form, I also acknowledge Receipt of ABLE Kids “Notice of Privacy Practices”(as required pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Notice provides detailed information about how the practice may use and disclose my confidential information and has reserved the right to make changes to the privacy practices that are described in the Notice.
Note: If the patient is incapable of signing or under the age of 18, a parent or legal guardian must sign in the patient’s place. In such cases, the parent or legal guardian is considered the ‘authorized person.’
Name of Client/Patient:*

First NameLast Name
Name of Legal Guardian or Parent (if applicable): *

First NameLast Name
Authorizing Signature: *

Clear
Date*

MonthDayYear
Date
AUTHORIZATION TO RELEASE INFORMATION,
AUTHORIZATION FOR ASSIGNMENT OF BENEFITS AND SIGNATURE ON FILE

By signing this authorization, I authorize:
- The release of any information concerning my childs health care, advice and/or treatment provided for the purpose of evaluation and administering claims for insurance benefits.
- Payment of benefits for such services to be assigned to and directly made to ABLE Kids
- The validation of all future insurance claims submitted on my behalf by the use of “Signature on File”. This form with your signature will be kept on file and shall be referred to when insurance Claim Forms are submitted for healthcare services you have received.
ACKNOWLEDGEMENT OF RESPONSIBILITY FOR PAYMENT

By signing this form, I AGREE TO PAY all charges incurred for services rendered by ABLE Kids, less any amounts paid by any third party payor/ insurance company. I guarantee the amount due for noninsurable charges including co-payment, deductibles, etc. to be paid within 60 days of receipt of invoice. I understand that I may revoke this consent in writing, except to the extent that the organization has
already taken action in reliance thereon.

Note: If the patient is incapable of signing or under the age of 18, a parent or legal guardian must sign in the patient’s place. In such cases, the parent or legal guardian is considered the ‘authorized person.’
Name of Client/Patient: *

First NameLast Name
Name of Legal Guardian or Parent (if applicable):*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
CLIENT INSURANCE INFORMATION
Client/Patient Information
Insurance Coverage*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Insurance Policy Holder/Insured Party
Name as it appears on policy:*
Policy Number:*
Relationship to Patient: *
Phone Number*
Please enter a valid phone number.
SSN:*
DOB:*
Primary Insurance Company:*
COPY OF THE FRONT AND BACK OF ALL INSURANCE CARDS MUST BE PROVIDED
Secondary Insurance Policy Holder/Insured Party
Name as it appears on policy:
Policy Number:*
Relationship to Patient:
DOB:
SSN:
Secondary Insurance Company:
COPY OF THE FRONT AND BACK OF ALL INSURANCE CARDS MUST BE PROVIDED
Please list any deductibles or copays for both Primary and Secondary Insurances:
I agree to pay any deductibles and co-pays that are within the treatment authorization and not covered by my insurance. I understand that I will not be billed for any services not provided. *

Clear

ABA Intake Packet

Requirements to Begin ABA Services include:

Documents Required For Authorization Request:

Consent to Video and Audio Recording in the Clinic

Information Related to Scheduling and Sessions

Intake Questionnaire

Family Information

Previous and Current Services

Medical History

EDUCATION HISTORY

DISCIPLINE INFORMATION

ADDITIONAL INFORMATION

BEHAVIOR

SPEECH

FINE MOTOR SKILLS

SLEEP

PARENT / FAMILY PRIORITIES & PREFERENCES

RAISD

INFORMED CONSENT FOR BEHAVIORAL SERVICES:

AUTHORIZATION FOR USE/DISCLOSURE OF HEALTH INFORMATION

Service Agreement and Consent Form

HIPAA PRIVACY AUTHORIZATION FORM

ACKNOWLEGE RECEIPT OF “NOTICE OF PRIVACY PRACTICES”

CLIENT INSURANCE INFORMATION