ABA Parent Handbook Acknowledgment and Consent

If someone else has legal authority to make medical or treatment decisions for this child, please provide the following information:

We understand that starting ABA therapy can feel overwhelming, especially if this is your family's first experience with services. Our goal is to guide you through every step of the process and partner with you throughout your child's treatment. Below is an overview of what you can expect during your ABA journey with A Core Connection.

Step 1: Referral Your journey typically begins when your child is referred for ABA services by a physician, psychologist, school, or another healthcare provider. Families may also contact us directly to inquire about services. During this stage we will: • Obtain your child's demographic information • Verify insurance eligibility and benefits • Collect required medical documentation • Answer any questions you may have about our services • Schedule the intake process Depending on your insurance plan, additional referrals or authorizations may be required before services can begin.

Step 2: Initial Assessment Once all required documents are received, your child will be scheduled for a comprehensive ABA assessment with one of our Board Certified Behavior Analysts (BCBAs). During the assessment, the BCBA may: • Meet with parents or caregivers • Observe your child • Review medical and developmental history • Identify your child's strengths and challenges • Assess communication skills • Evaluate social skills • Assess daily living skills • Identify behaviors that interfere with learning • Determine appropriate treatment goals The assessment allows us to create an individualized treatment program specifically designed for your child.

Step 3: Development of the Treatment Plan Following the assessment, your BCBA develops a personalized treatment plan based on your child's individual needs. The treatment plan may include goals related to: • Communication • Social interaction • Play skills • Daily living skills • School readiness • Independence • Behavior reduction • Safety skills • Parent training objectives Each goal is measurable and designed to help your child make meaningful progress.

Step 4: Insurance Authorization Before therapy can begin, the treatment plan must be submitted to your insurance company for review. The insurance company determines: • Whether services meet medical necessity requirements • The number of approved therapy hours • Length of authorization • Approved service codes • Parent training hours • BCBA supervision hours Authorization timeframes vary by insurance company and may take anywhere from several days to several weeks. Please note that A Core Connection cannot begin services until authorization has been received (unless private pay arrangements have been made).

Step 5: Beginning ABA Therapy Once authorization is approved, therapy services will begin. Services may occur: • At our clinic • In your home • At school • In the community (when authorized) Your child's therapy team may include: Board Certified Behavior Analyst (BCBA) The BCBA: • Oversees treatment • Creates programs • Reviews data • Trains staff • Meets with parents • Updates treatment plans • Monitors progress Registered Behavior Technician (RBT) The RBT: • Provides direct one-on-one therapy • Implements treatment goals • Collects data • Communicates session information • Works under BCBA supervision Therapy sessions focus on teaching new skills while reducing behaviors that interfere with learning.

Step 6: Parent Participation Parent participation is one of the most important factors in your child's success. Research consistently shows that children make greater progress when caregivers actively participate in treatment. Parent training may include: • Understanding your child's behavior • Learning behavior management strategies • Reinforcement techniques • Communication strategies • Teaching daily living skills • Generalizing skills at home • Reviewing progress • Problem-solving challenges Many insurance companies require parent participation as part of the authorization for ABA services. We encourage all caregivers to attend scheduled parent training sessions and actively participate in implementing strategies outside of therapy. 

Step 7: Ongoing Supervision and Reassessments ABA is an ongoing process that continually adjusts based on your child's progress. Throughout treatment, your BCBA will: • Observe therapy sessions • Review data • Modify teaching procedures • Introduce new goals • Fade mastered goals • Meet with caregivers • Train RBTs • Monitor treatment effectiveness Most insurance companies require periodic reassessments, typically every 6 months, although requirements vary by insurer. The reassessment includes: • Reviewing progress • Updating assessments • Measuring goal achievement • Identifying new areas of need • Developing updated recommendations • Requesting continued authorization from insurance These reassessments help ensure your child continues to receive medically necessary services.

Step 8: Discharge from ABA Services
Discharge is considered when ABA therapy is no longer medically necessary or when treatment goals have been achieved.
Reasons for discharge may include:
• Treatment goals have been successfully met
• The child demonstrates independence across environments
• ABA services are no longer medically necessary
• Transition to another level of care
• Family relocation
• Parent request
• Loss of insurance eligibility or funding
• Inability to participate consistently in treatment despite intervention efforts
• Safety concerns that cannot be adequately addressed
Before discharge, we work with families to develop a transition plan whenever appropriate.
This may include:
• Home recommendations
• School recommendations
• Community resources
• Referrals to other providers
• Maintenance strategies
• Follow-up recommendations
Our goal is to ensure your child continues to succeed even after ABA services have ended.

Your Partnership Matters
Successful ABA therapy is a partnership between your family and our team.
We are committed to:
• Providing compassionate, evidence-based care
• Keeping you informed throughout treatment
• Answering your questions
• Respecting your family's goals and values
• Working together to help your child reach their fullest potential
By working together, we can create meaningful progress and lasting positive outcomes for your child.

What to Expect:

1.       ACC staff will behave in a professional manner, including being trustworthy, considerate, polite, and discrete.

2.       ACC will provide consistent, high-quality treatment to you and your family. If a session must be cancelled, the staff will notify you in advance.

3.       ACC will keep an accurate written record of the treatment we provide.

4.       The use of recreational drugs or alcohol prior to or during sessions is not allowed.  If a staff member determines that a client or other person present for the session is under the influence of alcohol or drugs, he/she may decide to cancel the session. 

5.       The use of tobacco products is not allowed in our office or office building.  Use of tobacco is permitted in designated areas away from the building entrance or stairway.  Our staff are not allowed to use tobacco products in the presence of clients or their families.

6.       If a legally prescribed medication taken prior to or during a session impairs the ability of a client or other session participant to benefit from treatment, the staff may decide to cancel the session. 

7.       If a medical emergency occurs during a session, the staff will call 911 and follow the instructions given.

8.       If you or the staff are aware of an incoming natural disaster (e.g., hurricane, tornado, flood), check the National Weather Service and follow their instructions. If the weather service says that it is unsafe to drive, you may need to cancel and reschedule your session.  If you are at our office, the staff will stay at the office with you until it is safe to leave.  For home visits, the staff may need to remain at your home until the weather clears, and it is safe to drive again.

9.       Weapons of any kind are not permitted in an A Core Connection office.  During in-home sessions, all firearms must be maintained in a securely locked area.

10.   If the electricity in the office goes out for more than 15 minutes, your session will be cancelled and rescheduled.

11.   There is a fire extinguisher and a first aid kit in each office in case it is needed.

12.   Our focus is on helping the whole family, not just the client, so your family should plan to participate in family sessions once deemed appropriate.

13.   Sessions are scheduled on a regular basis; you will have a consistent schedule associated with your treatment. Efforts will be made to arrange appointments, which will be as convenient as possible for you to attend. At times, compromises will be necessary.

14.   Each client will have a unique schedule dependent on the results of the initial assessment. The Lead Analyst will indicate recommended hours for each client on the initial assessment report.

15.   An individualized treatment plan will be completed with the individual receiving services, parent/legal guardian, and the Analyst. All involved will voluntarily agree to follow the plan as outlined.

16.   Treatment length is depending on progress.

17.   ACC staff members are not on call and are unable to address issues outside of normal business hours (8:30 - 5:00). If a crisis situation occurs, you are advised to proceed to the nearest emergency room.

18.   You may be called by our office for a brief satisfaction survey at some point during treatment; your feedback is important to us.

19.   At a minimum of every 6 months, you, your family, and your Analyst will discuss your progress in a Reassessment, which your child and you will sign.

20.   By the end of treatment, the client should have met their goals for treatment. Your family (and teacher, if school services are provided) should also have learned some ways to help you or your child to do your best.

21.   At the final session, your Analyst will make sure that you are prepared with any services that you will still need after treatment ends.

Your Rights

1. Respect: You and your family will be treated with respect by all A Core Connection staff.
2. Anti-Discrimination: Your religious and cultural beliefs will be respected.  You will not be treated differently based on your age, disability, race, sex, or ethnic group.
3. Freedom of Choice: You have the right to change providers, refuse referrals for other services, or stop services at any time, without penalty
4. Confidentiality/Privacy: You have the right to decide when and with whom to share your private information.  Information about you will not be shared with other people without your permission. There are exceptions to this rule, including if we must report suspected abuse, neglect, or exploitation, if we believe someone’s life is in danger, or if a judge orders it. 
5. Access to Records: You have the right to read and have copies of your chart information in a timely manner.  We might require that we be present to explain what is written, however, and there may be a cost for some records
6. Grievances: If you make a complaint or file a grievance, your services will not be terminated or affected in any way.
7. Freedom from Harm: We are required by law to report any suspected abuse, neglect, or exploitation. If you need to report abuse, neglect, or exploitation, call the Abuse Hotline: 1-800-96-ABUSE (800-962-2873). 

  Your Responsibilities:

1. Attendance: You and your family will keep appointments and abide by the attendance agreement.
2. Participation: You and your family will participate in treatment and will follow through with the strategies agreed upon during treatment sessions.
3. Notification: You will inform the office of any changes to your insurance coverage address or phone number
4. Payment: You are responsible for any services, co-payments or deductibles not paid by your insurance. 

ACC has the right to terminate services if you fail to follow through on your responsibilities (listed above) or if we believe that maximum benefit has been reached. If your treatment is discontinued and you still need help, you will be given a referral to another agency that can help.

Consistency Leads to Success

At A Core Connection, we know that every therapy session plays an important role in your child's progress. ABA therapy is most effective when services are provided consistently and skills are practiced regularly. Just like attending school or participating in a sports team, regular attendance helps your child build upon previously learned skills and continue making meaningful progress toward their goals.

Because ABA services are considered medically necessary treatment, insurance companies also expect families to participate consistently. Frequent cancellations or missed appointments may impact your child's progress and, in some cases, could affect future insurance authorizations.

We understand that life happens, and our goal is to work together with your family whenever possible. The following guidelines help us provide consistent, high-quality services for all of the families we serve.

📅 Planned Time Off

If your child will be absent due to a vacation, holiday, planned medical appointment, or other scheduled event, please notify our office at least two (2) weeks in advance whenever possible.

Providing advance notice allows us to:

Coordinate your child's therapy schedule.
Offer make-up sessions when scheduling allows.
Adjust staff schedules appropriately.
Minimize disruptions to your child's treatment plan.
While we will make every effort to accommodate make-up sessions, they cannot be guaranteed and are based on therapist availability

🤒 Sick Days

The health and well-being of our clients, families, and staff are very important to us. If your child is ill or has symptoms of a contagious illness, please keep them home and notify our office as soon as possible.

Families are permitted up to four (4) illness-related absences within a three-month period without penalty.

Please notify the office by 8:00 AM whenever possible so we can notify your therapy team and adjust schedules accordingly.

If your child exceeds four illness-related absences within a three-month period, make-up sessions may be required when scheduling permits in order to maintain treatment consistency and medical necessity.

⏰ Arriving Late

We understand that unexpected delays can happen.

If you anticipate being late, please contact our office or your therapist as soon as possible.

If we have not heard from you within 15 minutes of your scheduled appointment time, your session may be canceled for that day.

Please note that therapy sessions will still end at their originally scheduled time to avoid impacting the schedules of other families and staff.

🚗 Parent Pick-Up

For clinic-based services, we ask that parents or authorized individuals arrive promptly at the end of each therapy session.

To ensure appropriate staffing and supervision:

A five (5) minute grace period is provided.
After the grace period, a late pick-up fee of $1.00 per minute will be assessed.
Outstanding late pick-up fees must be paid before your child's next scheduled therapy session.
If you are unexpectedly delayed, please notify the office as soon as possible.

📈 Why Attendance Matters

Consistent attendance is one of the strongest predictors of successful ABA treatment.

Regular participation allows your child to:

Build and maintain newly learned skills.
Generalize skills across environments.
Maintain momentum toward treatment goals.
Develop consistent relationships with their therapy team.
Receive the full benefit of their authorized treatment hours.
Frequent cancellations, late arrivals, or missed appointments can interrupt your child's progress and may result in:

Slower skill acquisition.
Difficulty maintaining previously learned skills.
Reduced treatment effectiveness.
Concerns regarding medical necessity from your insurance provider.
Possible reduction or loss of authorized therapy hours.
Loss of your regularly scheduled therapy time if attendance becomes inconsistent.
Our team will always work with families to address barriers to attendance whenever possible.

 🤝 We're Partners in Your Child's Success

We recognize that balancing appointments, work schedules, school, and family responsibilities can be challenging. Our goal is to partner with you to create a schedule that supports your child's success while meeting the requirements of their treatment plan.

Thank you for making your child's therapy a priority. Your commitment, participation, and consistency are essential components of successful treatment, and we appreciate the opportunity to work alongside your family.

Together, we can help your child build meaningful skills, greater independence, and lasting success.

We’re a team — your commitment helps your child succeed! 💙

Keeping Everyone Healthy

At A Core Connection, the health and safety of our clients, families, and staff is one of our highest priorities. Because many of the children we serve spend several hours in close contact with therapists and peers, illnesses can spread quickly within the clinic or during home-based services.

Our goal is to provide a safe and healthy environment where every child can participate successfully in therapy. If your child is not feeling well, we ask that you help us protect everyone by keeping them home until they are healthy enough to participate.

As a general guideline:

If your child is too sick to participate in school, daycare, or their usual daily activities, they are likely too sick to participate in ABA therapy.

When Should I Keep My Child Home?

Please notify the office as soon as possible if your child develops a contagious illness or experiences any of the following symptoms within 24 hours of their scheduled therapy session:

🌡️ Fever above 100.5°F (axillary/underarm) or fever requiring fever-reducing medication
🤢 Vomiting
💩 Diarrhea
👁️ Conjunctivitis ("Pink Eye")
🤕 Persistent complaints of ear pain, stomach pain, severe headache, or other significant discomfort
🩸 Bleeding that cannot be controlled with basic first aid or is more than a minor scrape or cut
🤧 Thick green or yellow nasal discharge accompanied by fever or other signs of illness, which may indicate an infection
🪲 Head lice or active nits
🦠 Any contagious illness diagnosed by a physician, including but not limited to influenza, COVID-19, strep throat, RSV, chickenpox, hand-foot-and-mouth disease, or other communicable illnesses
If you are unsure whether your child should attend therapy, we encourage you to contact our office before your appointment. We are happy to discuss the situation with you.

Returning to Therapy

To help protect everyone in our clinic, children should generally be:

Fever-free for at least 24 hours without the use of fever-reducing medication
Free of vomiting or diarrhea for at least 24 hours
Cleared by their healthcare provider when appropriate for contagious illnesses
Able to comfortably participate in their regular therapy activities
Some illnesses may require additional guidance from your child's physician before returning to therapy.

If Your Child Becomes Sick During Therapy

If your child develops symptoms of illness while participating in a therapy session, our staff will:

Monitor your child's health and comfort.
Contact the parent or legal guardian immediately.
Separate your child from group activities, when appropriate, while they wait to be picked up.
Request that your child be picked up as soon as possible to protect the health of other children and staff.
If your child requires emergency medical attention, staff will follow our emergency procedures and contact 911 if necessary.

Medications

If your child is taking medication for an illness, please inform the office before the session.

Please note that medication which reduces symptoms (such as fever-reducing medication) does not necessarily mean your child is well enough to participate in therapy. Children should be healthy enough to actively engage in treatment without significant discomfort or fatigue.

Working Together to Keep Everyone Healthy

We understand that unexpected illnesses happen and appreciate your cooperation in helping us maintain a healthy environment for all of our families.

By keeping sick children home and notifying us as soon as possible, you help:

Protect other children receiving therapy.
Reduce the spread of contagious illnesses.
Protect our therapists and staff.
Ensure your child is able to fully participate when they return.
Maintain a safe and healthy treatment environment for everyone.
Thank you for partnering with us to keep our clinic healthy, safe, and ready for learning every day.

For all in home families, please note that we have some guidelines in place to make sure that everyone is being considered when conducting therapy in your home environment.

Please know that you can openly communicate with the office if you have any concerns so that we can do our best to assess the situation and make sure that the environment works for all who are involved. 

·      You may be wondering what you, your spouse, and your other children should do during therapy sessions. Don't feel like you must lock yourselves in a room and stay quiet until sessions end. Working in a natural environment around daily routines is all part of the therapy. 

·      Promptly let us know if you have any questions about anyone or therapeutic interventions in your home. 

·      If you ever need to cancel or change a session date or time, inform the staff as soon as you can. If staff do not extend the same respect to you (let you know when they will be late or must cancel) immediately notify the office. 

 Before we arrive for a therapy session, please help us do our job by making sure your child is "therapy ready". This means they are awake, fed, diaper/pull up is dry, and they are not actively engaged with a highly preferred reinforcer or activity. In language your child will understand, let them know when we are coming so they will be prepared.

Our Commitment to Safety
At A Core Connection, the safety and well-being of every child, family member, and staff member is our highest priority. Our team is trained to use positive, evidence-based behavior support strategies to help prevent challenging behaviors and teach safer, more appropriate ways for children to communicate their needs.
Most behaviors can be safely managed through proactive planning, environmental supports, and individualized behavior intervention strategies. However, there may be rare situations in which a child's behavior creates an immediate risk of harm to themselves or others. In these situations, our staff will follow our Emergency Crisis Intervention procedures to protect everyone's safety while maintaining the child's dignity and respect.

Situations That May Require Emergency Crisis Procedures
Emergency crisis procedures may be necessary when a child displays behaviors that place themselves or others at immediate risk of injury, including but not limited to:
·         👊 Physical aggression toward another child, staff member, caregiver, or other individual.
·         🤕 Continuous or severe self-injurious behavior that may result in injury.
·         💥 High-magnitude disruptive behavior that creates an immediate safety concern, such as throwing large objects, overturning furniture, damaging property in a dangerous manner, or other behaviors that could result in injury.
·         🚪 Serious elopement or attempts to leave a safe environment when there is an immediate danger to the child.
·         ⚠️ Any behavior that presents an immediate threat to the health or safety of the child or others.
These situations are uncommon, but it is important that families understand how we respond should they occur.

Our Response to a Behavioral Crisis
Our staff are trained to respond in a calm, supportive, and professional manner. Every effort is made to help the child regain control while minimizing stress and maintaining safety
1.      🏠 Environmental Adjustments
Our first priority is to make the environment as safe as possible. Depending on the situation, staff may:
·         Remove potentially dangerous objects from the area
·         Increase the child's personal space.
·         Reduce noise or other environmental distractions.
·         Move other children to a safe location if needed.
·         Guide the child to a quieter or safer area when appropriate.
·         Use the least amount of physical assistance necessary while maintaining everyone's safety.
Whenever possible, staff will avoid physical contact and instead use proactive safety measures.

2. 🌿 Positive Behavioral Intervention & De-escalation
Our therapists are trained to use evidence-based de-escalation techniques before considering any restrictive intervention.
Strategies may include:
·         Speaking calmly and respectfully.
·         Offering choices when appropriate.
·         Redirecting the child to preferred or calming activities.
·         Allowing space and time for self-regulation.
·         Using visual supports or communication systems.
·         Following the child's individualized Behavior Intervention Plan (BIP).
·         Reinforcing calm and appropriate behaviors.
These interventions are individualized to each child's treatment plan and are designed to help the child regain emotional and behavioral control safely.

 

3.    ✋ Protective Physical Intervention (Last Resort)
Physical intervention is only considered when a child's behavior presents an immediate danger of serious physical harm to themselves or others and less restrictive interventions have not been successful.
If physical intervention becomes necessary:
·         Only staff who have received approved crisis intervention training may perform the intervention.
·         The least restrictive intervention appropriate for the situation will always be used.
·         The intervention will be used only for the amount of time necessary to maintain immediate safety.
·         Continuous monitoring of the child's well-being will occur throughout the intervention.
·         The intervention will end as soon as the child is calm and the immediate safety risk has passed.
Physical intervention is never used as punishment, discipline, retaliation, or for staff convenience. Its sole purpose is to protect the child and others from immediate harm.

4. 📞 Emergency Medical or Community Response
In the rare event that a behavioral crisis cannot be safely managed by trained staff, or if there is a medical emergency, A Core Connection may contact emergency responders by calling 911.
Emergency services may also be contacted if:
·         A serious injury occurs.
·         The child experiences a medical emergency.
·         Additional assistance is necessary to maintain safety.
·         Staff believe immediate emergency intervention is required.
When emergency services are contacted, parents or legal guardians will be notified as quickly as possible.

5. 🔄 Recovery & Post-Incident Procedures
Once the child has regained control and the situation is safe:
·         Any protective intervention will be immediately discontinued.
·         Staff will help the child transition back to a calm and supportive environment.
·         The therapy team will assess whether the child is ready to resume activities or if the session should end.
·         Parents or guardians will be notified promptly regarding the incident.
·         Staff will complete all required incident documentation according to agency policy.
·         The supervising BCBA will review the incident to determine whether modifications to the child's treatment plan or Behavior Intervention Plan are appropriate.
Our goal is always to learn from each situation and identify strategies that may help prevent similar incidents in the future.

Partnering with Families 

Behavioral crises can be stressful for both children and families. We want you to know that our team is committed to treating every child with compassion, dignity, and respect—even during difficult moments. 

If your child has a history of severe aggression, self-injury, elopement, or other significant safety concerns, we encourage you to share this information with your BCBA before services begin. This allows our team to proactively develop individualized strategies, prepare the environment, and ensure appropriate supports are in place to promote the safest and most successful therapy experience possible.
 
By working together, we can create a safe, supportive environment where your child can learn, grow, and develop meaningful skills while protecting the well-being of everyone involved.

We value the privacy and comfort of all families. At times, photographs or videos may be taken during normal program hours or outside activities connected with A Core Connection. These images may be used to promote ABA services in print, online, or other media formats. 

📷 Understanding & Agreement

·      🏫 Photos/videos may be taken at the ABA Center or during related activities.

·      🌐 Images may be used in print or online for promotional purposes.

·      📝 This consent remains in effect for the entire time the child is enrolled in A Core Connection ABA, unless updated in writing.

·      💰 There will be no payment or compensation for participation in this release.

 There are two (2) options. Please choose the one that applies to you.

   ✅ Permission Granted - I grant permission for my child(ren) listed above to be photographed or recorded for print or online use in promoting ABA services.

   🚫 Permission Denied - I do not grant permission for my child(ren) listed above to be photographed or recorded for print or online use in promoting ABA services.

Consent and Acknowledgment:
By signing below, I acknowledge that I have carefully read and reviewed all information contained on this form. I understand that this consent form is valid for one year from the date signed, unless otherwise specified or revoked in writing. After one year, the consent will expire, and a new consent will be required to continue services.         

I certify that:

I have the legal authority to authorize treatment for the above-named minor.  I understand that if my legal guardianship or custody status changes, I will notify A Core Connection immediately and provide updated legal documentation.

Your family's privacy is very important to us.

I acknowledge that I have received a copy of A Core Connection's Notice of Privacy Practices and understand how my child's protected health information may be used and disclosed. 

I understand that there are certain situations where A Core Connection is legally required to disclose information, including but not limited to:

• Suspected child abuse or neglect

• Threats of serious harm to oneself or others

• Court orders or other legal requirements

• Other situations described in the Notice of Privacy Practices

I understand these limits to confidentiality.

A Core Connection Services & Consulting, LLC. ("ACC") provides services including, but not limited to:

• Applied Behavior Analysis (ABA)

• Behavioral Assessments

• Mental Health Services

• Program Development

• Consultation

• Treatment Planning

I understand that treatment may involve structured teaching, movement, play-based activities, community activities, and interactive learning experiences.

Although A Core Connection takes every reasonable precaution to maintain a safe environment, I understand that participation in these activities carries a small risk of accidental injury, similar to other educational or therapeutic settings.

By signing below, I acknowledge that:

 I understand the nature of the services being provided.

 I voluntarily consent to treatment.

 I understand the potential risks associated with treatment activities.

  I understand that A Core Connection will use reasonable care in providing services.

  I understand that this Consent and Waiver is part of the agreement for my child to receive services.

I further acknowledge that I have had the opportunity to ask questions regarding this agreement and consult with legal counsel if I chose to do so before signing.

By signing this agreement, I acknowledge the potential risk of accidental injury that may occur during therapeutic activities despite reasonable safety precautions.

To the fullest extent permitted by law, I agree to release, waive, and hold harmless A Core Connection Services & Consulting, LLC., its owners, employees, and agents from liability for accidental injuries that may occur during the provision of services, except where prohibited by law or resulting from gross negligence or intentional misconduct.

I understand that this acknowledgment is an important condition of my child's participation in services.

To help provide the best care possible, I authorize A Core Connection to communicate with individuals involved in my child's treatment.

I authorize A Core Connection to release relevant confidential information to my insurance company or other funding source for the purposes of:

• Obtaining authorization

• Billing claims

• Receiving payment

• Responding to audits

I understand that I remain financially responsible for:

• Services not covered by insurance

• Copays, deductibles, or coinsurance

• Charges outlined in the Attendance Policy

• Charges resulting from insurance denials

• Claims denied due to undisclosed insurance coverage

I agree to notify A Core Connection in writing before any insurance changes become effective.

Please list anyone who may be contacted to care for your child if a parent cannot be reached in an emergency, and anyone authorized to pick up your child from ACC ABA Clinic.

Please note only those listed below will be authorized to pick up your child, unless you add them and sign a new document.

By signing below, I acknowledge that I have carefully read and reviewed all information contained in the attached consent packet, including all outlined pages. I understand the nature of the services, policies, and procedures described therein. I have had the opportunity to ask questions and have received satisfactory answers.

 I voluntarily consent to the services and agree to comply with the guidelines and terms presented. I understand that this consent packet is valid for one year from the date signed, unless otherwise specified or revoked in writing. After one year, the consent will expire, and a new consent will be required to continue services.