Welcome to 360 Human Services!
These are the forms we need on file before your child can begin services.
Please complete every section and sign on the last page.
Apple Valley: 18522 Outer Highway 18, Apple Valley, CA 92307
Barstow: 309 E Mountain View Ave, Barstow, CA 92311
San Bernardino: 2364 N Del Rosa, San Bernardino, CA 92404
Riverside: TBA
Informed Consent for ABA TreatmentI consent to my child being evaluated and treated at 360 Human Services using the principles of Applied Behavior Analysis (ABA), delivered by trained professionals under the supervision of a Board Certified Behavior Analyst (BCBA). I understand that goals will be set, reviewed, and updated by the clinical team, and that my active involvement is essential to my child's progress. If 360 Human Services cannot meet our needs, I will be referred to other appropriate providers. Signature*
HIPAA Privacy Notice — Acknowledgment of ReceiptI acknowledge that I have received the 360 Human Services Notice of Privacy Practices, which explains how my child's protected health information may be used and disclosed and outlines my rights under HIPAA. I understand a complete copy is available upon request and will be reviewed in detail at the Client Service Agreement meeting. Signature*
Attestation of Authority.I am the parent or legal guardian of the client named above and that I have the legal authority to consent to medical and behavioral health treatment and to authorize the release of health information on the client's behalf. I understand that if legal custody or decision-making authority is shared with or held by another person, 360 Human Services may require documentation (such as a custody order or guardianship papers) before beginning or continuing services. Signature*
Mandated Reporter NoticeI understand that all 360 Human Services staff are mandated reporters under California law and are required to report suspected child abuse or neglect to the appropriate state agency. Staff may also act, including notifying authorities, if a client appears to be a serious imminent danger to themselves or others. Signature*
Authorization to Bill InsuranceI authorize JFHS LLC d.b.a. 360 Human Services to bill my insurance carrier directly for ABA services rendered to my child and to receive payment on my behalf. I agree to pay any deductible, copay, coinsurance, or non-covered charge under my plan. Signature*
Authorization to Use, Release & Obtain Health Information (PHI)I authorize JFHS LLC d.b.a. 360 Human Services to use, release, and obtain my child's protected health information (PHI) for the purposes of assessment, diagnosis, treatment planning, ABA service delivery, billing, and care coordination.
Persons/entities authorized to share records WITH and receive records FROM 360 Human Services (answer all that apply and fill in names where requested):
Primary Care Physician — Name: Specialists / Therapists (OT, SLP, psychologist, psychiatrist, neurologist, etc.): School / IEP Team — School Name: Inland Regional Center (IRC) Service Coordinator: Prior / current ABA or behavioral health provider — Name: ☐ Other — specify: Date range of records requested:From Date to Date All available records: Yes No Other Other:
Effective period:This authorization is effective immediately and remains in effect until termination of services with 360 Human Services or until I revoke it in writing, whichever comes first. I may also specify an earlier end date here: Date Notice of Rights: