welcome to eclipse therapy...welcome to eclipse therapy dear family, star.ng therapy for your child...
TRANSCRIPT
WelcometoEclipseTherapy
DearFamily,
Star.ngtherapyforyourchildcanbeexci.ngaswellasoverwhelming.Wewillworktogethertoachievethegoalsyousetforyourchild.Includedinthispacketareasignificantnumberofforms.Pleasefeelfreetoaskmeanyques.onyouhaveviaemailorphone.
Iamexcitedtoembarkonthisjourneywithyourfamily.
Sincerely,Rosalie
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AnOverviewofEclipseTherapyLLC’sApproach
Mission:
Toensurethateveryfamilyhastheopportunitytoenjoythesimplepleasuresoflife:apeacefulfamilydinner,aquietgameofcards,amovienightout,oranevent-freetriptothegrocerystore.Eclipsewillprovideconsistentandexcep.onalbehavioranaly.cservicestochildrenwithdisabili.es.Servicesareprovidedtoop.mizethechild'sprogresstowardstheirindividualizedgoal.
Purpose:ThecornerstoneofEclipseTherapyistheunderstandingthatanyimpairmentordisabilitycanhaveadebilita.ngeffectonanindividualandthefamily.Withsteadfastloyalty,Eclipsewillstrivetenaciouslytoincreasethechild’sabili.esinanefforttoimprovethefunc.oningofthechildandfurthermoreincreaseharmonywithinthefamily.
Ourapproachtoworkingwitheachchild:
• Isindividuallytailoredtomeeteachchild'suniqueneeds• Isop.mizedtoensureyourchildisgainingskillsasquicklyaspossible• Isbasedonthemostcurrentresearch
Ourprogramingforau.smaddressesthemajorissuescommoninau.sm:
• Understandingandusinglanguage• Buildingbroadersocialskills• Communica.ngwithandrela.ngtopeers• Buildingageappropriateandsymbolicandplayskills• Buildingemo.onalregula.onskills• Increasingflexibilityandreducingrigidity• Increasingconceptualthinkingandcogni.veskills
Ourprogramingforchildrenwithotherdisordersisindividualtailoredbutwillincludetheseessen.alskills:
• Buildingemo.onalregula.onskills• Increasingdistresstolerance• Increasingcommunica.veabili.es• Increasingconceptualthinkingandcogni.veskills
EclipseTherapy’strainedtherapistsworkone-on-onewitheachchildcloselymonitoringresponsesinordertomatchthedifficultyofthematerialandmethodofinstruc.ontothechild'sabilitylevelandrateoflearning.Allourtherapistsholdatleastahighschooldiploma,haveextensivetrainingspecificallyinresearchsupportedtreatmentsforau.smspectrum
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disorders,behaviordisorders,andtheprincipalsofAppliedBehaviorAnalysis.Supervisionofeachchild'sprogramisprovidedbyoneofourBCBAwithregularprogressreviews.
Inaddi.ontotheindividualABAprogram,parenttraining,programstoaddressproblembehaviors,andarangeofbehavioranaly.cservicesareofferedthroughoutoursessions.Ourfocusisonhelpingyourchildgainskillsthatarecri.caltoyourfamilyandtheirfunc.oning.
Weprovidebehavioralassessments,parent&stafftraining,programsupervision,andqualityinhome/schoolABAprograming.Eachofourprogramsupervisorsisboardcer.fiedbytheBehaviorAnalysisCer.fica.onBoard.
Pleasecall720-339-1309forfurtherinforma.onorclarifica.on.
Instruc=onsforthispacketofinforma=on
Thispacketisratherlengthy,butitwillhelptheEclipseteambe^erunderstandyouchildandtheskillstheyneedtoacquireormaladap.vebehaviorsweneedtohelpreduce.Pleasebeasdetailedasyoucan.IfsomethingdoesnotapplytoyourchildpleasewriteNA.
YoucanfilloutthispacketusingaPDFfillerorprintandhandwrite.
Pages4-11and36inthisdocumentrequireyoursignature.Signaturesonthesepagesarenecessarytobegintreatment
Pleasereturnthispacketeitherbyemail,postalmail,orhanddelivertoyourchild’ssupervisor.Thesedocumentsmustbesubmi^edbeforetreatmentcanbegin.
Welookforwardtoworkingwithyourfamily!Pleasedonothesitatetocalloremailwithanyques.onsorconcerns.
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ConsenttoTreat
I,theundersignedparent,personhavinglegalcustodyorguardianship/authorizedcareproviderof__________________________________(the“minor”),doherebyauthorizeRosalieByrdPrendergast,MSBCBA,ofEclipseTherapyandanyofthebelowEclipseteammembers,LLCtoprovideand/orsupervisebehavioralhealthservices.Suchservicesmayinclude,butarenotlimitedtoBehavioralAssessment,BehavioralTreatment,andCounselingServices.Iunderstandthisauthoriza.onmayberevokedinwri.ngatany.me.
EugeniaLogvinova,MedBCBA
KatherineThomas,MSBCBA
AmandaMontoya,MSBCBA
TimothyMullins,MFTC
BritneyBonner,MFTC
DamianYoung,LMFT
KristyO’Brien,BCABA
Mandatorydisclosureforeachclinicianavailableuponrequest.Ifforanyreasonyouneedto
file a complaint or grievance below is informa=on to do so. At Eclipse we value your
partnershipandhopethatyouwillcometouswithanyconcernsthataraiseandprovideus
anopportunitytosolvetheproblem.
a. TheColoradoDepartmentofRegularlyAgencieshasthegeneralresponsibilityofregula.ngtheprac.ceoflicensedpsychologists, licensedclinicalsocialworkers, licensedprofessionalcounselors, licensed marriage and family therapists, cer.fied school psychologist, andunlicensed individuals who prac.ce psychotherapy. The agencywithin Office of LicensingUnlicensedPsychotherapist1560Broadway,Suite1350Denver,CO80202,(800)811-7648.
b. Many of us are also regulated by the Behavior Analyst Cer.fica.on Board. They can bereached at Behavior Analyst Cer.fica.on Board 2888 Remington Green Lane, Suite CTallahassee,FL32308850-765-0905
MandatoryDisclosureStatement
1. NameofTherapists:RosalieByrdPrendergast,MSBCBAEugeniaLogvinova,MedBCBAKatherineThomas,MSBCBAAmandaMontoya,MSBCBATimothyMullins,MFTCBritneyBonner,MFTC
Client/Parent/Guardian Signature Date
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DamianYoung,LMFTKristyO’Brien,BCABA
2. Degrees:RosaliePrendergast,MSBCBA:BA,UniversityofNorthernColorado,2004
MS,NovaSoutheasternUniversity,2009 BoardCer.fiedBehaviorAnalyst,2009 UnregisteredPsychotherapist#12185,2010
3.AgenciesIreportto:c. TheColoradoDepartmentofRegularlyAgencieshasthegeneralresponsibilityofregula.ng
theprac.ceoflicensedpsychologists, licensedclinicalsocialworkers, licensedprofessionalcounselors, licensed marriage and family therapists, cer.fied school psychologist, andunlicensed individuals who prac.ce psychotherapy. The agencywithin Office of LicensingUnlicensedPsychotherapist1560Broadway,Suite1350Denver,CO80202,(800)811-7648.
d. Many of us are also regulated by the Behavior Analyst Cer.fica.on Board. They can bereached at Behavior Analyst Cer.fica.on Board 2888 Remington Green Lane, Suite CTallahassee,FL32308850-765-0905
4.ClientRightsandImportantInforma.on:
a. You are en.tled to receive informa.on from me about my methods of therapy, thetechniques I use, the dura.on of your therapy (if I can determine it), andmy fee structure.Pleaseaskifyouwouldliketoreceivethisinforma.on.
b.Youcanseekasecondopinionfromanothertherapistorterminatetherapyatany.me.
c.Inaprofessionalrela.onship(suchasours),sexualin.macybetweenatherapistandaclientis never appropriate. If sexual in.macy occurs, it should be reported to the State Board ofPsychologistExaminers.
d.Generally speaking, the informa.onprovidedby and to a client during therapy sessions islegally confiden.al if the therapist is a cer.fied school psychologist, a licensed clinical socialworker,a licensedmarriageand family therapist,a licensedprofessionalcounselor,a licensedpsychologist, or an unlicensed psychotherapist. If the informa.on is legally confiden.al, thetherapistcannotbeforcedtodisclosetheinforma.onwithouttheclient’sconsent.
e.Thereareexcep=onstothegeneralruleoflegalconfiden.ality.Someoftheseexcep.onsarelistedintheColoradostatutes(seesec.on12-43-218,C.R.S,inpar.cular).Forexample,Iamrequiredbylawtoreportchildabuse.Thereareotherexcep.onsthatIwilla^empttoiden.fytoyou,iffeasibleatthe.me,assitua.onsariseduringtherapy.
Client/Parent/Guardian Signature Date
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Non-Discrimina=onPolicyStatement
ItisthepolicyofEclipseTherapytoprovideservicestoallpersonswithoutregardtorace,color,na.onalorigin,religion,sex,age,ordisability.Nopersonshallbeexcludedfrompar.cipa.onin,orbedeniedbenefitsof,andservice;orbesubjectedtodiscrimina.onbecauseofrace,color,na.onalorigin,religion,sex,age,ordisability.
Complaintofdiscrimina.onpolicyandprocedure:thispolicystatementcomplieswithCivilRightsAct,TitleVI(45CFRpart80.7B)andsec.on504oftheRehabilita.onActof1973(45CFRpart84.7b.Ifyoufeelthatyouhavebeendeniedabenefitorservicebecauseofyourrace,color,na.onalorigin,age,sex,disability,orreligionyoumayfileaComplaintofDiscrimina.onwiththefacilityadministratorofEclipseTherapy,eitherverballyorinwri.ng.Awri^enresponsewillbeissuedtoyouwithin21daysofthecomplaintno.ce.
Youmayalsofileacomplaintwithanexternalagency.Ifyouchoosetofileyourcomplaintinwri.ng,youmustincludeyourname,address,telephonenumber,andabriefdescrip.onofwhatoccurredwhichledyoutobelieveyouwerediscriminatedagainst.Ifyouneedassistance,thefacilityadministratorofEclipsetherapywillbeabletoassistyou
Youmayalsofileacomplaintofdiscrimina.onbycallingorwri.ngtheDepartmentofRegulatoryAgencies(DORA)DivisionofCivilRightsat(303)894-2997or1560Broadway#1050,Denver,CO80202
Pleasesigninreceiptofthispolicy.
Client/Parent/Guardian Signature Date
6
2091KerrGulchRdEvergreen,CO80439
720-339-1309AUTHORIZATIONTORELEASEINFORMATION
ClientNameDOB:
StreetAddress:City/StateZIP
IunderstandthisreleaseisvoluntaryandappliestoallprogramsandservicesoperatedundertheauspicesofEclipseTherapyLLC.Iunderstandthatmypersonallyiden-fiableinforma-on(PII)maybeprotectedbythefederalrulesforprivacyundertheFamilyEduca.onalRightsandPrivacyAct(FERPA),theHealthInsurancePortabilityandAccountabilityAct(HIPAA),and/orotherapplicablestateorfederallawsandregula.ons.IunderstandthatmyPIImaybesubjecttore-disclosurebytherecipientwithoutspecificwri^enconsentofthepersontowhomitpertains,orasotherwisepermi^ed.Ialsounderstandthattherecipientmaynotcondi.ontreatment,payment,enrollmentoreligibilityonwhetherIsignthisform,exceptforcertaineligibilityorenrollmentdetermina.ons.IunderstandthatImayrevokethisauthoriza=onat
any=mebyno=fyingEclipseTherapyLLCinwri=ngbutifIdo,itwillnothaveanyeffecton
anyac=onstakenbeforereceiptoftherevoca=on.
IherebyauthorizeEclipseTherapyLLCto(checkallthatapply):
❒Exchangewith❒Releaseto❒Obtainfromthepar=esIhaveindicatedbelow
IherebyauthorizeEclipseTherapyLLCtoexchange/release/obtaininforma=on:
❒Verballyonly❒Inwri^enformonly❒Bothverballyandinwri.ng
Organiza=onorIndividualreceiving/communica=ngtheinforma=on:
NameofOrganiza=on/Individual
AddressCity,StateZipPhone
Descrip=onofinforma=ontobeexchanged/released/obtained: ❒Educa.onrecords❒Evalua.on/assessment/eligibilityrecords❒Medicalrecords❒Other
❒Clinicalrecords(includingbehavioranaly.c,psychological,physical,occupa.onal,andspeechtherapiesDura=onofrelease(checkone):
❒Thisreleasewillremainineffectfortwo(2)years,unlessotherwises.pulatedorrevokedinwri.ng.
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❒From (MM/DD/YYYY)To(MM/DD/YYYY)Thepurposeifthisreleaseis:
FeeSchedule
BehavioralConsulta=onwithRosalieByrdPrendergast,MSBCBA,EugeniaLogvinova,Med
BCBA,KatherineThomas,MSBCBA,AmandaMontoya,MedBCBA,:
$140perhourplus$40perhourtraveledaccordingtoGoogleMaps.InHome/SchoolBehaviorTherapyMasterslevelclinician:
$120perhourplus$0.555permiletraveledroundtripaccordingtoGoogleMaps.InHome/SchoolBehaviorTherapywithRBTLevelClinicianPursuingCer=fica=on:
$85perhourplus$0.555permiletraveledroundtripaccordingtoGoogleMaps.InHome/SchoolBehaviorTherapywithRBTLevelClinician:
$50perhourplus$0.555permiletraveledroundtripaccordingtoGoogleMaps.Addi=onalChargesapplyingtoallservices:
Theseservicesmaybenecessaryforyourprogramandarebilledatyourclinician’shourlyrate.o Phoneconsulta.onlas.ngmorethan15minutes.o Wri^endocumenta.on(includingprogressreportsandotherformsofwri^en
communica.on)requiringmorethan15minuteso Emailmessagesrequiringmorethan15minutes.o Wri^enorverbalcommunica.onwith3rdpartypayers(includinginsurancecarriers,
CommunityCenteredBoards,etc.)requiringmorethan15minutes.o Crea.onofindividualizedtherapymaterialssuchas,butnotlimitedtobooksorstories
requiringmorethan15minutes.o Recordreviewrequiringmorethan15minutes.o Otherservicesaclientmayrequestrequiringmorethan15minutes.
PleaseSigninyouunderstandingoftheFeesChargedbyEclipseTherapyLLC.
Client/Parent/Guardian Signature Date
Printed name of the guardian
Client/Parent/Guardian Signature Date
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PaymentPolicy
EclipseTherapyLLCstrivestoofferthehighestqualityofcare.Neverwillyourcarebecon.ngentonyourinsuranceorwaivercoverage.Considerablecarehasbeentakentodetermineourrates.Wewanttoassureyouthatourchargesaccuratelyreflectthecomplexityofcarerenderedandtheskillandexper.serequiredforop.maltreatment.Ourfeesarecomparabletothoseofotherhighlyqualifiedspecialists.Whetheryouhavepurchasedinsuranceonyourown,youremployerhasprovidedittoyou,oryouhavequalifiedforamedicaidwaiver,youarefortunatetohaveitandwewillgotheextramiletohelpyoumaximizeyourbenefitsprovidedbyyourspecificplanorwaiver.Asacourtesytoyou,wewillfilewiththoseplanstowhichwehavebeenadmi^edasaprovider(InNetwork)andwhenrequestedandwehavenotbeenadmi^edasaproviderwillcompletethestandardCMS1500claimformforyoutoseekreimbursementthroughyourinsurer.Whenaserviceiscovered,yourinsurancecompanyusuallyonlypaysapercentageofthefee,andthisvariesfromcarriertocarrierandplantoplan.Yourinsuranceisnotdesignedtopaytheen.recostoftreatment,butitisintendedtohelpcoveracertainpor.onofthecost.
Pleaseremember,however,thefinancialobliga.onforourservicesarebetweenyouandEclipseTherapy,andisNOTbetweenEclipseTherapyandtheinsurancecompany.
Forclientschoosingtoprivatepayforservices,youwillbebilledmonthlyviaourQuickBooksonlineaccoun.ngsystem.Youwillreceiveabillbetweenthe1stand4thofthemonthfollowingservices.Paymentfortheseservicesisdueback30daysfromreceiptoftheinvoicefromEclipseTherapyLLC.
Paymenttoourofficeisnotcon.ngent,nordependentuponyourinsurancecompany.Allaccountbalancesmustbesa.sfiedwithin60daysofthedateserviceswerebilled,aterthat.mearebillingfeeof$10.00maybechargedtoyouraccount.Ifyouhaveanyques.onsregardingourfinancialpolicy,pleasedonothesitatetodiscussthemwithus.
Weacceptcash,check,andbanktransfersviaQuickBooksonline.
IunderstandandagreethatIamresponsibleforthepaymentofallchargesincurredregardlessofanyinsurancecoverageorotherplansavailabletome.Addi.onally,Iunderstandandagreetopayanyandallcollec.onscostsand/ora^orney’sfeesifanydelinquentbalanceisplacedwithanagencyora^orneyforcollec.on,suit,orlegalac.on.Ialsoacknowledgethatconfiden.alityiswaivedinma^ersinvolvingcollec.onsandthesharingofinforma.onsufficienttopursuerecoveryofdebtsowed.
Client/Parent/Guardian Signature Date
9
UsingWaiverServices
**Pleasefilloutareleaseofinforma.onforustocontactyourcasemanager**
Pleasenotethatwecannotbeginservicesun.lwehaveAuthoriza.oninwri.ngfromyourCaseManager.
Ifyouwouldliketobeginservicesonaprivatepaybasispriortoapprovalpleasesignbellow.
Pleasesigninunderstandingthatifyouschedulesessionthatgooverthenumberofhoursthatyouhaveapprovedthroughyourwaiveryouwillbebilledatprivatepayrates.
Type of Waiver
Community Center Board
Case Manager Name
Case Manager Email
Case Manager Supervisor
Client/Parent/Guardian Signature Date
Client/Parent/Guardian Signature Date
Client/Parent/Guardian Signature Date
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UsingInsurance
*******InsurancecoverageusuallyrequiresadiagnosisofAu=sm********
Pleasea^achapictureofthefrontandbackofyourcard.
Child’sName
DateofBirth
Child’sAddress
Child’sSS#
PhoneNumber
InsuranceCompany
Insurancecompanyphonenumber
GroupNumber
PolicyNumber
PlanType
PolicyHolder’sName
PolicyHolder’sDOB
PolicyHolder’sSSN
PolicyHolder’sEmployer
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HIPAAEmailConsent
VERYIMPORTANT!PLEASEREAD!
• HIPAAstandsfortheHealthInsurancePortabilityandAccountabilityActHIPAAwaspassedbytheU.S.governmentin1996inordertoestablishprivacyandsecurityprotec.onsforhealthinforma.on
• Informa.onstoredonourcomputersisencrypted.Mostpopularemailservices(ex.Hotmail®,Gmail®,Yahoo®)donotu.lizeencryptedemail
• Whenwesendyouanemail,oryousendusanemail,theinforma=onthatissentisnot
encrypted.This meansathirdpartymaybeabletoaccesstheinforma=onandreaditsinceitis
transmi\edovertheInternet.Inaddi=on,oncetheemailisreceivedbyyou,someonemaybeabletoaccessyouremail
accountandreadit.
• Emailisaverypopularandconvenientwaytocommunicateforalotofpeople,sointheirlatestmodifica.ontotheHIPAAact,thefederalgovernmentprovidedguidanceonemailandHIPAATheinforma.onisavailableinapdf(page5634)ontheU.S.DepartmentofHealthandHumanServiceswebsite-h^p://www.gpo.gov/fdsys/pkg/FR-2013-01-25/pdf/2013-01073.pdf
• Theguidelinesstatethatifapa.enthasbeenmadeawareoftherisksofunencryptedemail,andthatsamepa.entprovidesconsenttoreceivehealthinforma.onviaemail,thenahealthen.tymaysendthatpa.entpersonalmedicalinforma.onviaunencryptedemail
OPTION1–ALLOWUNENCRYPTEDEMAIL IunderstandtherisksofunencryptedemailanddoherebygivepermissiontoEclipseTherapyLLCtosendmepersonalhealthinforma.onviaunencryptedemail
OPTION2–DONOTALLOWUNENCRYPTEDEMAIL Idonotwishtoreceivepersonalhealthinforma.onviaemail
Pleaseprintemailaddress_______________________________
Client/Parent/Guardian Signature Date
Client/Parent/Guardian Signature Date
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AssignmentofBenefits
IauthorizepaymentofbehaviorhealthbenefitstoEclipseTherapyLLCand/orcliniciansatEclipseTherapyLLCfortheseservicesandallfutureclaims.Youshouldalsounderstandyouwillberesponsibleforallnon-coveredservicesbecauseoflackofauthoriza.onorforanyotherreasonfordenial.
Iauthorizethereleaseofnecessarymedicalinforma.ontoprocessinsuranceclaims.
PermissiontoPhotograph
IgivepermissionandconsentforEclipseTherapy,LLCtotakephotosofmychildand/ormyselfduringthe.memychildisenrolledinservices.Iunderstandthesephotographsmaybeusedineduca.onaltrainingpresenta.ons.
Child'sname:_____________________Dateofbirth:_________________
___________________________________________________________
PermissiontoVideotapeorAudiotape
IgivepermissionandconsentforEclipseTherapy,LLCtovideotapeand/oraudiotapemychildand/ormyselfduringthe.memychildisenrolledinservices.Iunderstandthesetapeswillnotbeusedoutsidethecompanyandwillbekeptconfiden.al.Iunderstandthatthetapeswillbeusedforthepurposesofdevelopingmoreeffec.veeduca.onalandtherapeu.cplansformychildandalsoforthepurposeofeduca.onandtrainingforEclipseTherapy,LLCandthefamily.
Client/Parent/Guardian Signature Date
Client/Parent/Guardian Signature Date
Client/Parent/Guardian Signature Date
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Child'sname:_____________________Dateofbirth:_________________
Inaddi.ontotheabove,IalsogivepermissionforEclipseTherapy,LLCtouserecordedvideosegmentstopresenttoparentsandprofessionalsforconferencesand/orothertrainingpurposes.
Child'sname:_____________________Dateofbirth:_________________
Client/Parent/Guardian Signature Date
Client/Parent/Guardian Signature Date
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CHILD&ADOLESCENTINTAKEQUESTIONNAIRE
Confiden=al
Thefollowingques.onnaireistobecompletedbythechild'sparentorlegalguardian.Thisformhasbeendesignedtoprovideessen.alinforma.onbeforeyourini.alappointmentinordertomakethemostproduc.veandefficientuseofour.me.Pleasefeelfreetoaddanyaddi.onalinforma.on,whichyouthink,maybehelpfulinunderstandingyourchild.EclipseTherapy,LLCwillholdinforma.onprovidedbyyouisstrictlyconfiden.alandwillonlybereleasedinaccordancewithHIPPAguidelinesandasmandatedbylaw.Pleaseusethebacksofthepagesforaddi.onalinforma.on.
PLEASEPRINT
Name of Person Completing this form
Legal Name of Child/Adolescent
Nickname or name child routinely goes by
Child's Date of Birth
Current Age
Age of Diagnosis
Home Address (Primary Residence)
Home Address (Secondary)
Home Telephone Number (primary)
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Pleasedescribetheproblemsyourchildisnowhaving,andwhattypeofservicesyouareseekingfromusfortheseproblems.Pleaseusethebackofthispageforaddi.onalspace.
Home Telephone Number (Secondary)
Work Telephone Number (Mother)
Work Telephone Number (Father)
Cell (Mother)
cell (Father)
School Name
Teacher
Grade
School telephone number
Grade
Who referred you to our practice
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INDICATEPARENT/GUARDIANSLIVINGINTHEHOME
MaritalStatus
Ifdivorced,
Mother’sInforma.on:
Father’sInforma.on
Married Remarried Devorced Separated Widowed Single Cohabitants
Who has physical custody
Is if full or joint
Who has legal custody
Is is full or joint
Mother’s Name
Date of birth
Age
SSN
Occupation
Employer
Education Completed
Health Condition
Mother’s Name
Date of birth
Age
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Doeseitherparent'sjobrequirehim/hertobeawayfromhomelonghoursorextendedperiods?
Religious/SpiritualAffilia.on
Siblings
Pleaselistaddi.onalSiblings
SSN
Occupation
Employer
Education Completed
Health Condition
Name Age Relationship School Grade
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PSYCHOLOGICALHISTORY
Isthereahistoryinyourimmediateorinthemother'sorfather'sextendedfamily,orthefollowingandifsowho?
Hasthechildyouareseekingservicesforbeenevaluatedinthepast?
IfYes,pleaselistthefollowinginforma.ononthepreviousevalua.on(s)(Ifmoreevalua.onsneedtobelistedpleaseusethespaceonthebackofthispage.Ifacopyisavailablepleasea^achforyourchild’scliniciantoreview)
YES NO
Autism Spectrum Disorders
Learning Problems/Disabilities
ADHD ADD Attention Problems
Depression
Bipolar
Behavior Problems in School
Anxiety Disorders
Psychosis/Schizophrenia
Substance Abuse or Dependence
Other Mental Health Concerns
Yes No
Date Evaluation Doctor Diagnosis
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Ifyes,whatweretheirgeneralfindingsandrecommenda.ons?
Pleaseprovideuswithanyotherinforma.ononthepsychologicalhistorythatyoufeelwouldbehelpfultousinunderstandingyourchild:
Pleaseincludecopiesoftheevalua.ons.
PRE-NATALANDDELIVERYHISTORY
Werethereanycomplica.onswiththePregnancy?
IfYes,pleaseprovidetreatmentdetails:
WasbirthatFullTerm?
IfNo,pleaseprovidedetail:
Yes No
Yes No
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TypeofDelivery:Spontaneous/InducedVaginal/C-Sec.on
Complica.ons?
IfYes,Pleaseprovidedetails:
ConcernsatBirth?
IfYes,pleaseprovidedetail-includinganytreatmentsgiven(Addi.onalspaceonbackifneeded):
Isthereanyaddi.onalpre-natalorbirthinforma.onthatmightbeofassistancetous?
Yes No
Birth Weight
Apgar
Yes No
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DEVELOPMENTALHISTORY
1.Pleaseindicatetheageatwhichyourchilddidthefollowing:
2.Pleaseindicateifyourchildisexperiencinganyofthefollowing:
Rolled over consistently
Sat up unsupported
Stood
Crawled
Walked
Dressed Self
1st words
Said Intelligible work to stranger
Used phrases
Talked in Sentances
Potty Trained During the Day
Dry through the night (6+ months)
Problems with eating
Isolated socially from peers
Problems making friends
Problems keeping friends
Problems getting to sleep
Problems controlling temper
Nightmares
Bed Wetting / Soiling
Problems with authority
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Listanyopera.on,seriousillnesses,injuries(especiallyhead),hospitaliza.ons,allergies,earinfec.ons,orotherspecialcondi.onsyourchildhashad.
Listanymedica.onsyourchildiscurrentlytakingorhastakenforextendedperiods(givedosagelevelifpossible):
Child’scurrent:
Withwhichhanddoesthechildwrite
Anxiety
Unmotivated
School concentration difficulties
Grades dropping or consistently low
Sadness or Depression
Substance Abuse
Hospitalization Cause Date Allergies
Medication Dose Start Date
Height
Weight
Left
Right
I don’t know
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7.Doesthechildhaveanyvisionproblems?Pleaselistdateoflastvisiontestandwhoperformed(pediatrician,optometrist,School)
8.Doesthechildhaveanyhearingproblems?
Pleaselistdateoflasthearingtestandwhoperformed(pediatrician,optometrist,School)
9.Physicianinforma.on
Name
Practice Name
Address
Phone Number
Fax
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EDUCATIONHISTORY
Listinchronologicalorderallschoolsyouchildhasa^ended:
SpecialEd?
Name(s)ofcurrentteacher(s)
Doesyourchild'steacherhaveconcernsabouthim/her(list)
Whatisyourchild'sfavoritesubject/class?
Whatisyourchild'sleastpreferredsubject/class?
Name
District
Years
Grade
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Hasyourchildeverrepeatedagrade?Y/NIfyes,whatgrade(s)?:
IfyourchildhasbeeninSpecialEduca.on,didtheyhavea:
IfyourchildhasbeeninSpecialEduca.on,howweretheyserved?
504 Plan
Occupational Therapy Evaluation
Physical Therapy Evaluation
Adaptive Technology Evaluation
I.E.P.
Psychological Evaluation
Special Evaluation
Behavior Intervention Plan
Consultation
Resource Classroom
Team Taught Classes
Self-Contained Classroom
Psycho educational Center
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Child'sextracurricularac.vi.es,includingsports,clubs,hobbies,lessons,etc.
10.Listanyspecialabili.es,skills,strengthsyourchildhas:
ACADEMIC
Doyoufeelyourchild'sacademicskilllevelisappropriate?
Wouldyoulikeustoaddressacademicskillsdevelopment?
Collaborative Education
Pull-Out
Special Program
Football Baseball
Cheerleading Basketball
Karate Piano
Scouts Soccer
Dance (type) Music (type)
Gymnastics (type)
Yes No
Yes No
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Coun=ng
Canyourchildiden.fynumbers?
Othernumberskills:
All Some None
Single Digit Numbers1-10
Double Digit 10-99
Higher
Yes NoCan count to 10Can count to 20Can count 20+Can your child count out a number of objects up to 5Can your child count out a number of objects up to 10Can your child count out a number of objects up to 10+Can he/she complete simple addition math problems? (Single digit) Can he/she complete simple subtraction problems?
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Reading
Canyourchildiden.fyle^ers?
ReadingComments:
All Some None
Lowecase
Uppercase
Identify letter sounds
Yes NoIdentify blends (e.g. sh, st, cr)Can sound out words with blendsCan read simple words (2-4 letter simple words - cat, dog, sat)Can read longer words and sight words (there, just, jump) Can sound out unknown wordsCan read simple sentencesCan comprehend what he/she is reading (can understand and answer questions about what's been read)
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SELFCARE
Doesyourchilddresshim/herself?
Doyouhavesafetyconcernsregardingyourchild'sac.vi.esathome?
Explain:
Self-CareComments:
Independent With Assistance Does Not
Does your child bathe him/herself?Grooming (brushing teeth, combing hair)Does your child clean up after him/herself
Independent With Assistance Does Not
Independent With Assistance Does Not
Independent With Assistance Does Not
Yes No
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ATTENDING/ENGAGEMENT
Engagement
A^endingComments:
Always Sometimes Never
DoesyourchildmakeeyecontactwithothersAnswerorlookwhennameiscalledDoesyourchildfollowgesturesfromothersDoesyourchildengageinactivitiesorgamesthatarenottheirideaCanyourchildappropriatelyplaybyhim/herself?
WithDistraction
Canyourchildanswerquestionswhenthereisbackgroundnoise,otherpeople,distraction?Doesyourchildappeartounderstanddirectionsandquestions?Doesyourchildappeartohaveagoodmemory?
31
BEHAVIOR
Tantrums/Aggression/Self-Injury:Doesyourchildhavetantrumsthatyoufeelneedtobe
address?
Describebehavior:
Whattriggersatantrum?
Frequency
Doesyourchildreactaggressivelyat.mes?
Yes NoWhen told "no" (you can't have that/can't do that)When he/she is not getting attention or wants attention To avoid non preferred activitiesTo escape a non preferred task/activity For no obvious reason
1 or more per month
One or more per week
One or more per day
One or more per hour
Yes No
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Describeaggressivebehaviors:
Whattriggersaggressivebehavior?
Frequency
DoesyourchildengageinSelf-injuriousbehavior(hurthimselforherself)?Describeself-injuriousbehavior:
WhatTriggersSelfInjuriousBehavior
Yes NoWhen told "no" (you can't have that/can't do that)When he/she is not getting attention or wants attention To avoid non preferred activitiesTo escape a non preferred task/activity For no obvious reason
1 or more per month
One or more per week
One or more per day
One or more per hour
Yes NoWhen told "no" (you can't have that/can't do that)
33
Frequency
PhysicalStereotypicBehavior:
Frequency
When he/she is not getting attention or wants attention To avoid non preferred activitiesTo escape a non preferred task/activity For no obvious reason
1 or more per month
One or more per week
One or more per day
One or more per hour
Yes NoDoes your child flap his hands/arms Does your child seem to look at his fingers in a stereotypic way Does your child seem to look out of the side of his/her eyes Does your child walk on his/her toes Does your child rock (sit and rock back and forth)
1 or more per month
34
VerbalStereotypicBehavior:
Frequency
Persevera.on:
One or more per week
One or more per day
One or more per hour
Yes NoEcholalia (repeats what is said/heard Immediate) Delayed Echolalia (will repeat what's been said/heard later)Self-talkHumming to self - inappropriate Screech or yell inappropriately for no apparent reason Scrip videos or cartoon
1 or more per month
One or more per week
One or more per day
One or more per hour
35
Frequency
Transi.on/Rou.nes:
Frequency
Yes NoDoes he/she get stuck on a topicGet obsessive about specific peopleGet obsession about specific objects
1 or more per month
One or more per week
One or more per day
One or more per hour
Yes NoHas trouble with sudden changeHas trouble with changes that they are warned aboutDoes your child fear any specific objects, animals, places or people?
1 or more per month
One or more per week
36
Fears:Ifyes,explain
SENSORYISSUES
Doesyouchildhavesensi.vityto(ifyesexplain):BehaviorComments:
Frequency
SensoryComments:
One or more per day
One or more per hour
Sound Light Touch Texture Smells
1 or more per month
One or more per week
One or more per day
One or more per hour
37
IMITATIONOFMOVEMENTSANDSPEECH
Imita.onComments
SPEECH
Doyouhaveconcernsregardingdyspraxiaorapraxia?
Ifyesexplain
Doesyourchildrepeatwhathe/shehasheardotherpeopleorTVcharacterssay?
Ifyesexplain
Doesyourchilduseacommunica.onsystemsuchasPECS,sign,augmenta.vedevice,etc?
Yes NoCan imitate movements when they are demonstrated (clap hands, touch head when someone else is doing the same and he/she is asked to "do this" or "clap hands") Can imitate motions that go along with a song Can imitate a word or words when told to "say_____"
Yes No
Yes No
38
Ifyesexplain
_
SpeechComments:
LANGUAGE
Doesyourchildappeartounderstandlanguage?
Wordsinisola.on-caniden.fyobjectswhenasked
Caniden.fyac.ons("whereistheboywhoisrunning"whenshownapicturesofkidsplaying)
Caniden.fydescribingwords(redvs.blue,bigvs.li^le)
Canunderstandsimplesentences("drinkyourmilk.")
Canunderstandmorecomplexsentences("gogetyourredshoes,"or"givemetheonethatisnotwet")
Canhe/shefollowdirec.ons?
Yes No
Always Sometimes Never
Yes No
Yes No
Always Sometimes Never
Yes No
Yes No
39
withdelay("ateryoufinishea.ng,gogetyourshoes")
Doesyourchildusethefollowingwhenspeaking:
LanguageComments:
Yes No
One Step Two Step Three Step
Always Sometimes NeverUse when speaking
Nouns (people, places and things)Verbs (action words)Adjectives (describing words)Prepositions (in, out, on etc.)Pronouns (I, you, she, he)Simple sentences (3-4 word)Sentence Descriptors (it’s a black dog
Use Language To request needs/wantsTo greet othersTo respond to greetingsAnswer simple questions
40
SOCIAL/PLAY
Doesyourchildseekoutsocialinterac.onwith:___adults____siblings____peers
SocialComments:
FINEMOTORSKILLS
Always Sometimes NeverDoes your child play
Independently
Next to others
With other children
With toys
Games Skills
Plays gamesTakes turns independentlyNeeds assistance
Verbal SkillsTalks to peers during playTalks to self during playdoes not talk
What hand do the write with Left Right Don’t know
Always Sometimes NeverFine Motor
Hold a pencil
Trace
41
Doyouhaveconcernsregardingyourchild'sgrossmotorskills?
Explain:
PARENT/FAMILYPRIORITIES&PREFERENCES
Topthreeareas/goalsyouwouldliketoseechangeforyourchildinnext6months:
INTERVENTIONSTYLES
Inordertoaccomplishgoalssetforyourchild,werelyonavarietyofresearch-basedmethodsandstyles.Weassessyourchild'sneedsandemploymethodsthatwillmaximizeyourchild'sskillacquisi.on.Belowyouwillseealistofvariousstyles.Wewouldliketounderstandyourfamiliaritywitheachinterven.ontypeasthoseyouthinkmaythinkwouldworkbestforyourchild'spersonality/needsatthis.me.PleasesnotethatthisisNOTanexhaus.velistofmethods.
Copy Letters
Copy Words
Yes No
1
2
3
STYLE/METHOD Familiar with style/method?
May use with my child?
Errorless learning (teaching without allowing errors)
Y N DK Y N DK
Fluency based instruction/precision teaching
Y N DK Y N DK
42
AreyoucurrentlyseeinganyABAprovidersorotherBehavioralHealthProviders(psychiatrist,psychologist,counselor,ect)Y/NIfsopleaselistandfilloutaconsenttoreleaseinforma.onforcon.nuityofcare:
Functional Communication Training
Y N DK Y N DK
Incidental Teaching (following child's lead) around the house
Y N DK Y N DK
Incidental Teaching (following child's lead) in structured play
Y N DK Y N DK
One-to-one intervention (discrete trial) at desk or table
Y N DK Y N DK
PECS (Picture Exchange Communication System)
Y N DK Y N DK
Peer play dates Y N DK Y N DK
Positive Behavior Support working through behaviors and replacing behaviors with appropriate skills
Y N DK Y N DK
Self-management plans (for behavior other skills)
Y N DK Y N DK
Sign Language Y N DK Y N DK
Social Groups Y N DK Y N DK
Use of food as "reinforcer" (with the intent to fade as quickly as possible - we only use as a place to "start" if needed)
Y N DK Y N DK
43
SUPPORTINGBEHAVIORS
Some.meswhenteachingourclientsappropriatereplacementbehaviors,studentsmaybecomeupsetorcry.Whenthishappens,weareveryadeptatworkingthroughtheseinstanceswithfavorableoutcomes.Wewanttounderstandhowyoufeelaboutthiswhenithappens.(Pleasenotethatallbehaviorsupportplansarediscussedwithparentsandstrategiesforrespondingareexplainedandapproved.Providerscandebriefparentsaterany"difficult"sessionsaswell.)
_______Iamcomfortablewithledngmychildcryandledngprovidershandlethesitua=on_______IamNOTcomfortablewithledngmychildcryandledngprovidershandlethe
situa=on_______Iamunsureatthis=me
Comments:
DISCIPLINEINFORMATION:
Parentsmayuseawiderangeofdisciplinestrategieswiththeirchildren.Listedbelowareseveralexamples.Pleaseratehowlikelyyouaretouseeachofthestrategieslisted:
Discipline Strategy How Likely Rating
Let situation go 1 2 3 4 5
Take away a privilege (ex., no TV)
1 2 3 4 5
Take away something material
1 2 3 4 5
Assign an additional chore 1 2 3 4 5
Physical Punishment 1 2 3 4 5
Reason with child 1 2 3 4 5
44
GobackandratetheTHREEMOSTeffec.vestrategies.Thatis,placea1bythemosteffec.ve,a2bythenextmosteffec.ve,anda3bythethirdmosteffec.ve.PleasecircletheLEASTeffec.ve.
Pleaseratewhatpercentageofdisciplineishandledbyeachofthefollowing:Father:_____%Mother:____%Other:_____%(PleaseSpecify:)_________________________________
Pleaselistthefivethingsyouwouldlikeforyourchildtodomoreofandlessofinorderofprioritytoyou.Forexample,insteadofsaying,"Iwantmychildtobemoreresponsible,"translatethatintoactualbehaviorssuchasdohouseholdchores,careforbrothersandsister,etc.
Send to room 1 2 3 4 5
Ground child 1 2 3 4 5
Send to time out 1 2 3 4 5
Yell at child 1 2 3 4 5
Ignore child 1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
Like child to do more often Like child to do less often
45
ParentGuidelinesandPolicies
Yourcoopera.ononthefollowingisgreatlyappreciatedtoassistusinworkingwithyourchildatanop.mallevel:
1. Aparentorresponsibleadultmustbeinthehomewhentherapyisbeingprovided.2. Thetherapistmustwait15minutesifchildisnotthereatthetherapy.meandthenis
allowedtoleave.Youmaybechargedforthesessionandthisisnotbillabletoinsurance.3. Thetelephonenumbersofalltherapistswillbegiventoparentssotheycancontact
theirtherapistdirectly.Pleasedonotcallthetherapistsbefore8amandnotater9pm.4. Parentsshouldcontactatherapist24hourspriortotheappointmentiftheparent
knowstheyaregoingtocancelasession.Ifmorethan25%ofsessionsarecancelledina3-monthperiod,yourchildmaylosetheirtherapyslot.
5. Sickness.Pleaseno.fythetherapist,asmuchinadvanceaspossible,atleastthenight,beforethescheduledsessionifyouknowthatyourchildwillnotbeabletopar.cipateintherapythenextday.Sicknessincludes,butnotlimitedtothefollowing:
a. Temperatureabove100b. Mumpsc. RingWormd. CommunicableDiseasee. ChickenPoxf. StrepThroatg. Foot/MouthDiseaseh. Measlesi. Licej. Vomitk. Diarrheal. Rashm. PinkEye
6. Parentsareaskedtousethesameguidelinesusedinaschool-ifachildistoosicktoa^endschool,heorsheistoosicktopar.cipateinhis/hertherapysession.Therapywillresumeassoonasthechild'sdoctorclearshim/herofbeingcontagiousortheremedyiscompleted.Ifatherapistarrivesatthehomeandthechildissick,thetherapistwillnotbeabletoworkwithyourchild.
7. Thetherapistwillcall/textthefamilyiftheyaregoingtobearrivingmorethen5minuteslate.
8. Ifparentscancelasession,thesehoursarenotmadeupunlessthetherapistagreestodoso.
9. Ifatherapistcancelsasession,thesehoursmaybemadeupassoonaspossibledependingonthetherapistavailability.
10. Therapyschedulesshouldbeconsistenttoreduceschedulingerrors.Clearlytherewill
46
beoccasionslikeadoctorsvisitwhereasessionmaybemoved,butthatshouldbeararityratherthanthenorm.
11. Atherapistcannotchangeappointment.meswithoutagreementwiththefamily.12. Inthecaseofsnoworinclementweather:
a. Pleaselistentotheradioforannouncementsofschoolclosingforthedistrictinwhichyoureside.Ifthedistrictschoolsarecloseditisanindica.onthatdrivinginthatareapresentsdangerEclipseTherapytherapistshouldnotreporttoworkthatday.
b. Sinceschoolsinthedistrictareclosedoninclementweatherdays,the.memissedonthosedayscanbemadeupatthediscre.onofthetherapistandthefamily.
13. Incaseofanaccidentorunusualincident,thetherapistshouldcompleteaformandinformthefamilyandtheirsupervisorwithin1businessday.
14. Parentsandtherapistshouldberespec{ulandcourteoustoeachother.Opencommunica.onbetweenparentsandtherapistisessen.altotheestablishmentofasuccessfulprogramforthechild.Allcommunica.onmustbedoneinacourteousandrespec{ulmanner.Ifthereareanyproblemsorconcerns,pleasecontacttheBCBAorBCaBASupervisorimmediately.
15. Parentsareencouragedtosharewiththerapistsanyinforma.onthatmaybehelpfulinge|ngtoknowtheirchildandwillenablethemtoworksuccessfullywiththechild.
16. Periodicvideotapingofsessionsmaybehelpfulinassessingtheprogressofthechild.Priortoavideotapingsession,permissionmustbeobtainedbyallpar.esinvolvedandcanbeterminatedatany.me.Addi.onally,parentsmayrequestacopyofthetapedsessiononamediumprovidedbythem.
17. EclipseTherapyfeelsthatitisimportanttoincludeallfamilymembersintherapy.a. Siblingsarewelcometopar.cipateintherapyaslongastheyareahelpful
addi.ontothesession.b. Parentsarewelcomeandshouldpar.cipateintherapysessions.c. Cheatsheetsspecifictoyourchildwillbecreated.Therapistandsupervisorswill
goovertheseindetailandprovidemodelingandcoachingforyouonthesestrategies.
Informa=onRelatedtoSchedulingandSessions
Contac=ngus
Giventheirmanyprofessionalcommitments,ourtechniciansareotennotimmediatelyavailablebytelephoneoremail.Ifyouneedtoleaveamessage,wewillmakeeveryefforttoreturnyourcalloremailpromptly(within24hourswiththeexcep.onofholidaysandweekends.).Ifyouaredifficulttoreach,pleaseleavesome.meswhenyouwillbeavailable.Becauseofthenatureoftheservicesweprovide,wedonotprovideon-callcoverage24hoursperday,7daysaweek.Inemergencyorcrisissitua.ons,pleasecontactyourphysician,orcall911and/orgotothenearesthospitalemergencyroom.
ServicesOffered
47
Wewillprovideservicesspecificallydesignedtohelpyourchild,orifwecannothelpwewillprovideyouwithreferralstootherprofessionalswhomaybeabletoserveyourchildandhis/herneeds.Ourbehavioralservicesconsistprimarilyofassessments,inhome/schoolbehavioralservices,parenttraining,andongoingcollabora.onwithotherprofessionals.
YourchildwillhaveanABAtechnicianorteamofABAtechnicianfromEclipseTherapyassignedtohis/hercase.Eachtechnicianhasatleasthighschooldiplomaandhascompleteda40-hourtraininginAppliedBehaviorAnalysisandvaryingexperienceprovidingservicestochildrenwithAu.smandotherbehavioral/developmentaldifficul.es.ABoardCer.fiedBehaviorAnalystorBoardCer.fiedassistantBehaviorAnalystoverseesallcases.
ABAsessionsareusuallyscheduledintwo-threehourblocks.Theresearchisclearthatlongersessionsresultingreaterreten.onandthismakesschedulingmoreconvenientforallpar.es.Ifthisisnotconvenientforyourfamily,pleasebringthisupduringattheintakemee.ng.
Exceptincasesofemergency,24hoursno.ceisrequiredforallcancelledappointments.Paymentfortheappointmentisrequiredforallmissedappointmentsnotcancelledaccordingtothispolicy.Insurancecarriersarenotresponsibleformiss-appointmentfees.
Werequestthatfamiliesgiveusatleasttwoweeksno.ceonsignificantchangesintheirplansforin-homeABAsessionsschedulinginordertofacilitateconsistencyinservicedelivery.
ThestandardofcareoutlinedintheABAInterna.onal'sRevisedGuidelinesforConsumersofAppliedBehaviorAnalysisServicestoIndividualswithAu.smincludessupervisionoftherapistsonanongoingbasis,programconsulta.on,programreview,andprogramrevisionasservicesperformedbyaBCBA.Theseservicesarenecessaryforaprogramtomeetminimumprofessionalstandardsandarenotop.onal.
Appointments
Exceptforrareemergencies,wewillseeyourchildatthe.mescheduled.Weunderstandthatcircumstances(suchasanillnessorfamilyemergency)mayarisewhichnecessitatestheoccasionalcancella.onofappointments.Inthesecases,inordertoavoidanymisunderstanding,weaskthatyouspeaktoyourtherapistpersonallyandgiveasmuchno.ceaspossibletocancelorreschedule.Thiswillallowustobestplanforthesitua.on.
Youmaybechargedthestandardhourlyrate(seefeeschedule)forappointmentsmissedorcancelledwithlessthan24hoursadvanceno.ce.Pleasenotethatinsurancecompanieswillnotreimburseyouformissedappointmentsandyouremainresponsibleforthesecharges.
Cancella=onandSessionA\endancePolicy
48
Cancella.onsmustbedonenolessthan24hourspriortothescheduledsession.Iftheclientcancelsmorethantwo.meswithout24-hourno.ce,EclipseTherapycanreduceordiscon.nueservices.
Clientswillpar.cipatein80%ofscheduledsessionspermonth.Otherwise,theclientwillhaveonemonthtoreach80%par.cipa.oncriteria,orEclipseTherapycanreduc.onordiscon.nua.onofservices.Excep.onsmaybemadeifthereareextrememedicalcondi.onsthatrequirehospitaliza.on,andadoctor’snote.
Clientswillprovideaminimumof2weeksno.ceforvaca.onslas.ngmorethan3days.Iftheclientdoesnotprovide2weeksno.cemorethanonce,Eclipsecanreduceordiscon.nueservices.
Confiden=ality,Records,andReleaseofInforma=on
Servicesarebestprovidedinanatmosphereoftrust.Becausetrustissoimportant,allservicesareconfiden.alexcepttotheextentthatyouprovideuswithwri^enauthoriza.ontoreleasespecifiedinforma.ontospecificindividuals,orunderothercondi.onsandasmandatedbyColoradoandFederallawandourprofessionalcodesofconduct/ethics.Theseexcep.onsarediscussedbelow.
Toprotecttheclientorothersfromharm
Ifwehavereasontosuspectthataminor,elderly,ordisabledpersonisbeingabused,wearerequiredtoreportthis(andanyaddi.onalinforma.onuponrequest)totheappropriatestateagency.Ifwebelievethataclientisthreateningseriousharmtohim/herselforothers,wearerequiredtotakeprotec.veac.onswhichcouldincludeno.fyingthepolice,andintendedvic.m,aminor'sparents,orotherswhocouldprovideprotec.on,orseekingappropriatehospitaliza.on.
ProfessionalConsulta=ons
BehaviorAnalystsrou.nelyconsultaboutcaseswithotherprofessionals.Insodoing,wemakeeveryefforttoavoidrevealingtheiden.tyofourclients,andanyconsul.ngprofessionalsarealsorequiredtorefrainfromdisclosinganyinforma.onwerevealtothem.Wewilltellclientsabouttheseconsulta.ons.Ifyouwantustotalkwithorreleasespecificinforma.ontootherprofessionalswithwhomyouareworking,youwillfirstneedtosignanAuthoriza.onthatspecifieswhatinforma.oncanbereleasedandwithwhomitcanbeshared.
HealthInsurance
Ifwefileyourinsuranceclaims,youareresponsibleforco-payment.Youarealsoresponsibleforalloranypor.onofthebillthatyourinsurancedoesnotcoverordenies.
49
ProfessionalRecords
Youshouldbeawarethat,pursuanttoHIPAA,wekeepclients'ProtectedHealthInforma.oninonesetofprofessionalrecords.TheClinicalRecordincludesinforma.onaboutreasonsforseekingourprofessionalservices;theimpactofanycurrentorongoingproblemsorconcerns;assessment,consulta.ve,ortherapeu.cgoals;progresstowardsthosegoals,amedical,developmental,educa.onal,andsocialhistory;treatmenthistory;anytreatmentrecordsthatwereceivefromotherproviders;reportsofanyprofessionalconsulta.ons;billingrecords;releases;andanyreportsthathavebeensenttoanyone,includingstatementsforyourinsurancecarrier.
Pa=entsRights
HIPAAprovidesyouwithseveralneworexpandedrightswithregardtoyourClinicalRecordanddisclosuresofprotectedhealthinforma.on.Theserightsincludereques.ngthatweamendyourrecord;reques.ngrestric.onsonwhatinforma.onfromyourClinicalRecordisdisclosedtoothers;reques.nganaccoun.ngofmostdisclosuresofprotectedhealthinforma.onthatyouhaveneitherconsentedtonorauthorized;determiningtheloca.ontowhichprotectedinforma.ondisclosuresaresent;havinganycomplaintsyoumakeaboutourpoliciesandproceduresrecordedinyourrecords;andtherighttoapapercopyofthisAgreement,thea^achedNo.ceform,andourprivacypoliciesandprocedures.Wearehappytodiscussanyoftheserightswithyou.
Pleasesignsta.ngyoureceivedtheparentguidelinesandpolicies
Client/Parent/Guardian Signature Date
50
FUNCTIONAL ASSESSMENT SCREENING TOOL (FAST)
Name: ____________________________________ ___ Age: ___________ ___ Date: _________ _
BehaviorProblem: _______________________________________________________________ _
Informant: ___ -'--__________________ _ Interviewer: ______________________ _
To the Interviewer. The Functional Analysis Screening Tool (FAST) is designed to identify a number of factors that may influence the occurrence of problem behaviors. It should be used only as an initial screening toll and as part of a comprehensive functional assessment or analysis of problem behavior. The FAST should be administered to several individuals who interact with the person frequently. Results should then be used as the basis for conducting direct observations in several different contexts to verify likely behavioral functions, clarify ambiguous functions, and identify other relevant factors that may not have been included in this instrument.
To the Informant: After completing the section on "Informant-Person Relationship," read each of the numbered items carefully. If a statement accurately describes the person's behavior problem, circle "Yes." If not, circle "No." If the behavior problem consists of either self-injurious behavior or "repetitive stereotyped behaviors," begin with Part I. However, if the problem consists of aggression or some other form of socially disruptive behavior, such as property destruction or tantrums, complete only Part II.
Informant-Person Relationship Indicate your relationship to the person: __ Parent ___ Teacher/lnstructor ___ Residential Staff ___ Other
How long have you known the person? __ Years ___ Months
Do you interact with the person on a daily basis? __ Yes ___ No
If "Yes," how many hours per day? If "No," how many hours per week? ___ _
In what situations do you typically observe the person? (Mark all that apply) __ Self-care routines
__ Leisure activities
___ Academic skills training ___ Work/vocational training
___ Meals
___ Evenings __ When (s)he has nothing to do __ Other: _____________ _
Part I. Social Influences on Behavior 1. The behavior usually occurs in your presence or in the presence of others Yes No
2. The behavior usually occurs soon after you or others interact with him/her in some way, such as delivering an instruction or reprimand, walking away from (ignoring) the him/her, taking away a "preferred" item, Yes No requiring him/her to change activities, talking to someone else in his/her presence, etc.
3. The behavior often is accompanied by other "emotional" responses, such as yelling or crying Yes No Complete Part/l if you answered "Yes" to item 1, 2, or 3. Skip Part/l if you answered "No" to all three items in Part I.
Part II. Social Reinforcement 4. The behavior often occurs when he/she has not received much attention Yes No
5. When the behavior occurs, you or others usually respond by interacting with the him/her in some way (e.g., comforting statements, verbal correction or reprimand, response blocking, redirection) Yes No
6. (S)he often engages in other annoying behaviors that produce attention Yes No
7. (S)he frequently approaches you or others and/or initiates social interaction Yes No
8. The behavior rarely occurs when you give him/her lots of attention Yes No
9. The behavior often occurs when you take a particular item away from him/her or when you terminate a preferred leisure activity (If "Yes," identify: ) Yes No
10. The behavior often occurs when you inform the person that (s)he cannot have a certain item or cannot engage in a particular activity. (If "Yes," identify: ) Yes No
11. When the behavior occurs, you often respond by giving him/her a specific item, such as a favorite toy, food, or some other item. (If "Yes," identify: ) Yes No
12. (S)he often engages in other annoying behaviors that produce access to preferred items or activities. Yes No
13. The behavior rarely occurs during training activities or when you place other types of demands on him/her. (If "Yes," identify the activities: ____ self-care __ academic __ work __ other) Yes No
Adapted from the Florida Center on Self-Injury
Functional Assessment Screening Tool Page 2
14. The pehavior often occurs during training activities of when asked to complete tasks.
15. (S}he often is noncompliant during training activities or when asked to complete tasks.
16. The behavior often occurs when the immediate environment is very noisy or crowed.
17. When the behavior occurs, you often respond by giving him/her brief "break from an ongoing task.
18. The. behavior rarely occurs when you place few demands on him/her or when you leave him/her alone.
Part III. Nonsocial (Automatic)Reinforcement 19. The behavior occurs frequently when (s}he is alone or unoccupied
20. The behavior occurs at relatively high rates regardless of what is going on in his/her immediate surrounding environment
21.. (S}he seems to have few known reinforcers or rarely engages in appropriate object manipulation or "play' behavior.
22. (S}he is generally unresponsive to social stimulation.
23. (S }he often engages in repetitive, stereotyped behaviors such as body rocking, hand or finger waving, object twirling, mouthing, etc.
24. When (s}he engages in the behavior, you and others usually respond by doing nothing (Le., you never or rarely attend to the behavior.)
25. The behavior seems to occur in cycles. During a "high" cycle, the behavior occurs frequently and is extremely diffieult to interrupt. During a cycle the behavior rarely occurs.
26. The behavior seems to occur more often when the person is ill.
27. (S}hehas a history of recurrent illness (e.g., ear or sinus infections, allergies, dermatitis).
Scoring Summary Circle the items answered "Yes." If you completed only Part 1/, also circle items 1, 2, and 3
Like/r.. Maintaining Variable
1 2 3 4 5 6 7 8 Social Reinforcement (attention)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes -,>
Yes
Yes
1 2 3 9 10 11 1? .13 Social Reinforcement (access to specific activities/items) 1 2 3 14 15 16 17 18 Social Reinforcement (escape)
19 20 21 22 23 24 Automatic Reinforcement (sensory stimulation)
19 20 24 25 26 27 Automatic Reinforcement (pain attenuation)
Comments/Notes:
Adapted from theFIorida Center on Self-Injury
Nt;)
·NcIl No
No
No
No
No
No
No
No
No
No
No
No