FTC ABA Intake Packet Logo

  • ABA INTAKE PACKET

  • Thank you for taking the time to fill out this form. Please make sure each section is read, understood and signed.

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  • Consent for Applied Behavior Analysis (ABA) Services

  • This form describes the agreement to use professional Applied Behavior Analysis (ABA) services including the method of ABA assessment and treatment, rights of the client, and limitations of these services.  Agreement to fees and payments will be arranged separately. This form will need to be signed before an initial assessment, before the onset of ABA treatment, with each change in treatment services and with each annual or semi-annual re-assessment.

  • I, {nameOf319} agree to allow my child {childsName314} to participate in ABA services including assessments and treatment provided by Firefly Therapy Clinic. I understand that all goals, interventions, activities and possible outcomes will be reviewed with me and agreed upon before these services are applied, and that I will have the opportunity to ask questions, get clarification, and request changes prior to signing this document. I also understand that I can ask questions at any point of service delivery and that I can request changes, pauses, and discontinuation of services if I see fit. If services are being provided in conjunction with a third party (e.g., insurance company), I understand that the third party will also have a say in the determination and implementation of services as well as access to session documents, assessment reports and progress reports for the purpose of billing and remittance of payment. I also understand that my child is the primary client of Firefly Therapy Clinic and recommended services will be made primarily for {childsName314} 's benefit.

  • Communication Expectations

    I understand that Behavior Analysts are ethically required to recommend evidence-based services and that other treatments and therapies that my child participates in could affect ABA treatment. I agree to communicate all current and future treatment, therapy, and medication changes to the Behavior Analyst at Firefly Therapy Clinic as soon as I am aware of the change. I also understand that ABA therapy is most effective when attendance meets prescribed amounts, and that not meeting my child’s ABA therapy attendance requirements could reduce the effectiveness of treatment.

  • Confidentiality

    I understand that Firefly Therapy Clinic will take all reasonable steps to protect my privacy per HIPAA requirements.  I understand that the service provider will not discuss my child’s treatment with anyone outside of Firefly Therapy Clinic without first gaining my consent to disclose the information. When other families are present in the clinic during my child’s sessions, I understand that staff will not discuss my child or my child’s programs with anyone outside of my child’s service team.

  • Limits to Confidentiality

    I understand that there are some limitations to confidentiality in certain circumstances.  This includes times when the service provider believes that my child is in severe, immediate danger to themself or others. Also, because staff are mandated reporters,  I understand that the behavior analyst or behavior therapists may break confidentiality when making a report to child protective services if there is a concern of suspected abuse. Confidentiality may be breached when lawfully required or when a third party is needed to gain payment for services.  I understand that my child’s assessment and treatment at Firefly Therapy Clinic will occur alongside other children receiving services and could be seen by other therapists, children, and families participating in ABA services who are not part of my child’s service team. Additionally, I understand that Firefly Therapy Clinic trains ABA staff on a variety of strategies across individuals and that staff members in-training may be observing my child’s assessment or therapy for training purposes.

  • Photography, Video and Audio Recording

    I understand that Firefly Therapy Clinic uses video, photograph, and audio recording for the purpose of supervising and training staff and that these recordings will not be distributed, used on social media, or used for any other purpose than training and supervising staff.

  • Discontinuing Services

    I understand that the duration of treatment is based on the individual needs of my child. Ongoing data-collection, analysis, and assessment will allow the service provider to determine the level of support needed.  I understand that the amount of ABA treatment needed may change over time as my child builds skills and approaches behavioral levels that are similar to peers of the same age. When it is determined that ABA services are no longer medically necessary, I understand that services will be discontinued.  Additionally, if my child does not make progress with the recommended services, and does not show improvement after all programmatic changes and improvements have been made, I understand that I will receive a referral to another practitioner and services will be discontinued through a step-down reduction as appropriate.  

  • Initial Assessment

    During an initial assessment, I understand that Firefly Therapy Clinic will require me to complete several online questionnaires, surveys, and rating scales to gain information about my child. I will also be asked to give specific details about my child’s behaviors and situations or people involved in behavioral events. I understand that these items are time-sensitive and that not completing them in a timely fashion could result in delays in treatment for my child.  I understand that I will meet with the service provider to describe my concerns, as well as my child’s skills, preferences, dislikes, and challenges. I understand that the service provider will also attempt to work directly with my child in order to assess skills, deficits, and behavioral challenges, which may require 1-3 hours and could span across one or two meetings. Once the assessment has been completed and I have finished and submitted all online assessments, I understand that the service provider will schedule a meeting with me to review the assessment report and treatment plan with recommended goals and strategies, including instructional procedures and behavior intervention plan. 

  • Provision of Treatment

    Prior to beginning treatment with my child, I understand that the service provider will meet with me to discuss all prescribed goals, strategies, interventions, and treatment parameters of instructional procedures and behavior intervention plans. ABA treatment includes therapeutic interventions provided directly to my child by Firefly Therapy Clinic staff.  I understand that this includes preventative strategies to encourage skill-building and understanding in my child; reactive strategies to foster continued skill development and discourage problematic behaviors; and guided responding that can include the use of modeling, gesturing, vocalizing, and physical guidance to help my child complete responses. I understand that these strategies will be evidence-based, individualized for my child, and that I can ask questions and request changes at any time in order to have full participation in my child’s therapy. I also understand that I will be expected to take a role in my child’s therapy by practicing ABA strategies, participating in training, and taking notes and data on behaviors. I understand that my full participation will be critical to my child’s progress including my attendance at parent training sessions and progress meetings, as well as completing data-taking and note-taking activities on a regular basis.

  • Treatment Updates

    When changes need to be made to my child’s ABA therapy services, such as to instructional procedures or behavior intervention plan, I understand that I will be asked to approve of and consent to recommended changes.  I understand that this can be after a change is suggested by me or the service provider, such as when adding new goals, changing or adding behaviors targeted for reduction, changes to intervention strategies. While this is most likely to be needed with quarterly, semi-annual, or annual progress updates, I understand that changes may be requested by me or the provider any time they are deemed necessary. Suggested changes will be evidence-based, individualized and can include preventative strategies to encourage skill-building and understanding in my child; reactive strategies to foster continued skill development and discourage problematic behaviors; and guided responding that can include the use of modeling, gesturing, vocalizing, and physical guidance to help my child complete responses. I understand that these strategies will be evidence-based, individualized for my child, and that I can ask questions and request changes at any time in order to have full participation in my child’s therapy. I also understand that I will be expected to take a role in my child’s therapy by practicing ABA strategies, participating in training, and taking notes and data on behaviors. I understand that my full participation will be critical to my child’s progress including my attendance at parent training sessions and progress meetings, as well as completing data-taking and note-taking activities on a regular basis.

  • Reassessment

    When re-assessment is needed due to changes in skills or behaviors, or when requested by the third party, I understand that I will be asked to complete rating scales, surveys, and questionnaires needed for assessment purposes. I understand that these items are time-sensitive and that not completing them in a timely fashion could result in delays in treatment for my child. Additionally, my child will receive a direct assessment of skills and behaviors. I understand that this can include a review of my child’s progress as well as assessing new and current areas of development. Once the assessment has been completed and I have finished and submitted all online assessments, I understand that the service provider will schedule a meeting with me to review the assessment report and treatment plan with recommended goals and strategies, including instructional procedures and behavior intervention plan. 

  • Aknowldegement of Consent

    I understand the policies and procedures regarding my child’s ABA assessment and treatment.  I have been given an opportunity to ask questions, request changes, and collaborate with my child’s treatment. I understand that my consent is voluntary and that I can withdraw my consent at any time without penalty or recourse.
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  • Legal Intake Documents

    Please complete each section

  • Acknowledgement of Risk

  • In consideration of the services of Firefly Therapy Clinic their officers, agents, employees, and stockholders, and all other persons or entities associated with those businesses (hereafter collectively referred to as “FTC”) I agree as follows: Although FTC has taken reasonable steps to provide me with appropriate equipment and skilled guides so I can enjoy an activity for which I may not be skilled, FTC has informed me this activity is not without risk. Certain risks are inherent in each activity and cannot be eliminated without destroying the unique character of the activity. These inherent risks are some of the same elements that contribute to the unique character of this activity and can be the cause of loss or damage to my equipment, or accidental injury, illness, or in extreme cases, permanent trauma or death. FTC does not want to frighten me or reduce my enthusiasm for this activity, but believes it is important for me to know in advance what to expect and to be informed of the inherent risks. The following describes some, but not all, of those risks. The hazards of walking on uneven terrain, slips and falls; slipping and falling on the rock wall, crashing on trampoline, falling from the swing, being hit by a ball or toy, falling from a chair, choking, allergic reaction; my own physical condition and the physical exertion associated with these activities. I am aware that FTC entails risks of injury or death to any participant. I understand the description of these inherent risks is not complete and that other unknown or unanticipated inherent risks may result in injury or death. I agree to assume and accept full responsibility for the inherent risks identified herein and those inherent risks not specifically identified. My participation in this activity is purely voluntary; no one is forcing me to participate, and I elect to participate in spite of and with full knowledge of the inherent risks. I acknowledge that engaging in this activity may require a degree of skill and knowledge different from other activities and that I have responsibilities as a participant. I acknowledge that the staff of FTC has been available to more fully explain to me the nature and physical demands of this activity and the inherent risks, hazards, and dangers associated with this activity. I certify that I am fully capable of participating in this activity. Therefore, I assume and accept full responsibility for myself, including all minor children in my care, custody, and control, for bodily injury, death, or loss of personal property and expenses as a result of those inherent risks and dangers identified herein and those inherent risks and dangers not specifically identified, and as a result of my negligence in participating in this activity. I have carefully read, clearly understood, and accepted the terms and conditions stated herein and acknowledge that this agreement shall be effective and binding upon me, my heirs, assigns, personal representative, and estate and for all members of my family, including minor children.

  • Attendance Policy

  • Appointments are scheduled into available standing appointment slots. Once you have been scheduled into an appointment time, the therapist has committed this time to you. All scheduling must go through the front office.

    If you are unable to keep a scheduled appointment, you must give ample notice (within 24 hours of the appointment time

    Missing or cancelling any 3 appointments out of 5 continuous appointments will result in your child being immediately removed from the schedule. More than 1 no-show may also result in your child being immediately removed from the schedule.

    As in accordance with clinic policy and for the respect of patient, no children (other than those being treated by the therapist) are allowed in the gym or treatment rooms. Please keep any visiting children in the waiting area.

    If the parent or guardian leaves the clinic during the patient’s session, they must return 5 minutes prior to the end of the session. Therapists and office staff cannot be held responsible for children beyond the scheduled appointment time

    If your child is seen at preschool or daycare, and your child is not in attendance on the scheduled day of therapy, it is your responsibility to contact the therapist to inform them of a cancellation for that day,

    Please Note: Due to limited scheduling availability, we ask that all patients attend their scheduled treatments. When an appointment is applied to our schedule, that time is reserved to meet your child’s needs. We work hard to accommodate each of our patients. Continuous neglect to follow the regulations stated in this policy could lead to termination and/or change of status to your remaining treatments and/or sessions. Thank you in advance for your understanding and cooperation in this matter.

  • HIPPA Consent

  • I give Firefly Therapy Clinic LLC my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations such as quality reviews. Communication may be include, but is not limited to hospital, medical service company, health care company, insurance company, workers compensation carrier, welfare departments, patients employer, previous therapy clinics, school teachers/aids/administrators and Primary Care Physicians. I have been informed that I may review the practice/clinic's Notice of Privacy Practices for a more complete description of uses and disclosures before signing this consent. I understand that this practice/clinic has the right to change their privacy practices and that I may obtain any revised notices at the practice/clinic. I also understand that I may revoke this consent at any time by making a request in writing, except for information already used or disclosed.

    All information obtained will be kept private and used only for the planning of services or for billing for services provided

    Please list the names of service providers to help faciliate communication with childs care team. Communication will not be limited to this list and will default to all current members of childs team of providers and educators.

  • Authorization for Treatment

  • I consent to the treatment necessary for the below named patient. This is behavior analysis/therapy and/or any other related services that the provider or physician advise to be necessary.

  • Payment/Insurance Authorization

  • I authorize for all insurance/Medicaid payments to be made directly to Firefly Therapy Clinic LLC for therapy services rendered. I acknowledge that I am financially responsible for all charges not covered by this assignment. I further acknowledge that my insurance company may limit therapy benefits. I will be responsible for all charges accrued if my insurance denies service. I authorize Firefly Therapy Clinic LLC to release to the Social Security Administration, its intermediaries or carrier's information needed for the claim or any related Medicare Claim.

     

    Private Pay rates are available for families with no insurance/inactive insurance or with insurance that does not cover services. Please see the front desk for more information. Private Pay rates are not available to families that have active insurance.

  • Parent/ Guardian Drop off - Pick Up Policy

  • Firefly Therapy Clinic allows drop off and pick up of children during therapy. We require all parents, guardians and others who are dropping off, or picking up to follow these Guidelines.

    • Bring the child into the waiting room and stay with them until the therapist has arrived to take them back for treatment. Please do not leave children unattended in the waiting room
    • Arrive a minimum of 5 minutes prior to the end of the appointment to pick up the child
    • Children will NOT be released to anyone other than the parent or guardian signing this intake packet, unless listed below
    • Should you require a non listed individual to pick up your child, please contact the clinic prior to the appointment so we may update our list. 

    THERAPIST WILL NOT RELEASE A CHILD TO ANYONE other than the signer of this intake, without them being added to this list OR with verbal or written consent.

  • Authorization and Consent Form

  • I have read and understand the intake packet and sign below as agreement to each section 

    • Acknowledgment of risk
    • Attendence Policy
    • Authorization for Treatment
    • Payment/Insurance Authorization
    • HIPPA Consent
    • Parent/Guardian Pick Up Policy
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