ABA HOME SERVICES INTAKE PACKET

ABA HOME SERVICES
INTAKE PACKET
 Intake Form (complete all parts)
 Notice of Privacy Practices (keep)
 Notice of Privacy Practices Acknowledgement
(sign)
 Informed Consent and Service Agreement (do
not sign until first meeting)
 Authorization for Release and Exchange
Information Form (complete and sign for all
entities exchanging personal health information
with IBC; make additional copies if necessary)
 Payment Policy (sign)
Please include the following documents (if
available) with your intake packet:
 Current or most recent IEP/IFSP
 Copies of psychological reports with diagnosis
 Recent assessments/evaluations
2340 Powell Street  Suite 347  Emeryville, CA 94608
Phone: (510) 306-1422  Fax: (855) 249-5322
www.interactbehavior.com
INTAKE FORM
Today’s Date: ____/____/____
CHILD INFORMATION
Child’s name: ____________________________________________________ DOB:____________
Address: ________________________________ City: ____________________ State: ___ Zip _____
Phone: ____________________
FAMILY INFORMATION
Mother’s/guardian’s name: _____________________________________ Work #: _______________
Occupation: ________________________________________________________________________
Address (if different from client): _______________________________________________________
City: _______________________ State: ___ Zip _____
Email address: ____________________________________
Father’s/guardian’s name: _____________________________________ Work #: _______________
Occupation: ________________________________________________________________________
Address (if different from client): _______________________________________________________
City: _______________________ State: ___ Zip _____
Email address: ____________________________________
Marital status of parents: _____ Married _____ Separated _____ Divorced _____ Single
Parent(s) with Custody of Child: ________________________________________________________
Was child adopted?  Yes
Revised 8/10/11
Client Initials ___________
 No
1
FAMILY INFORMATION (CON’T)
Siblings
Name: _______________________________________________________________ Age: ___________
Name: _______________________________________________________________ Age: ___________
Name: _______________________________________________________________ Age: ___________
Family history of developmental disability or mental illness?  Yes
 No
Condition: ____________________________________ Relation to client: _________________________
Condition: ____________________________________ Relation to client: _________________________
SCHOOL INFORMATION
School district: ________________________________ Name of school: _______________________
Grade: _______________ Date enrolled: _______________ Date of recent IEP: _________________
Placement:  Inclusion/General Ed
 Mainstream
 SDC
 Non-public school
Days and times of attendance:_____________________________________________
REGIONAL CENTER
Is the child a client of a Regional Center?  Yes
 No
Which office? _____________________________ Caseworker:__________________________________
Address: ___________________________________ City: ____________________ State: ___ Zip _____
Phone: _______________ Email: _____________________
RELATED SERVICES – Current and past services received (e.g., ABA, OT, SLP)
Service/Therapy: __________________________________________________
 School
 Home
Provider: _____________________________________ Dates of service: FROM ________ TO_________
Agency address: _______________________________________________________________________
Phone: _______________
May we contact?  Yes
 No
Hours per week _____________
Progress observed: _____________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Revised 8/10/11
Client Initials ___________
2
RELATED SERVICES (CON’T)
Service/Therapy: __________________________________________________
 School
 Home
Provider: _____________________________________ Dates of service: FROM ________ TO_________
Agency address: _______________________________________________________________________
Phone: _______________
May we contact?  Yes
 No
Hours per week _____________
Progress observed: _____________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Service/Therapy: __________________________________________________
 School
 Home
Provider: _____________________________________ Dates of service: FROM ________ TO_________
Agency address: _______________________________________________________________________
Phone: _______________
May we contact?  Yes
 No
Hours per week _____________
Progress observed: _____________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Service/Therapy: __________________________________________________
 School
 Home
Provider: _____________________________________ Dates of service: FROM ________ TO_________
Agency address: _______________________________________________________________________
Phone: _______________
May we contact?  Yes
 No
Hours per week _____________
Progress observed: _____________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Revised 8/10/11
Client Initials ___________
3
MEDICAL HISTORY
Physician: _______________________________________ Phone: _______________________________
Is your child currently taking medication?  Yes
 No
Medication
1).______________________________ Dosage: _________ Administration Times:___________
Used for: ________________________
2).______________________________ Dosage: _________ Administration Times:___________
Used for: ________________________
3).______________________________ Dosage: _________ Administration Times:___________
Used for: ________________________
Were there complications with the pregnancy?  Yes
 No
If so, please explain: ____________________________________________________________________
_____________________________________________________________________________________
Are there concerns about your child’s hearing?  Yes
Hearing assessment conducted?  Yes
 No
 No
Any childhood illnesses? _________________________________________________________________
DEVELOPMENTAL HISTORY
What age did your child:
Sit up independently:
___________
Crawl:
___________
Walk:
___________
Eat solids:
___________
Sleep through the night: ___________
At what age did you suspect problems about your child’s development? ___________
Has your child exhibited any loss of skills in any area?  Yes  No If so, please explain ______________
_____________________________________________________________________________________
_____________________________________________________________________________________
Revised 8/10/11
Client Initials ___________
4
SOCIAL AND PLAY SKILLS
Describe how your child plays: ____________________________________________________________
_____________________________________________________________________________________
Does your child play independently?  Yes  No
If so, for how long? With what items/toys? _________
_____________________________________________________________________________________
Does your child play with toys appropriately?  Yes
 No
Explain: ____________________________
_____________________________________________________________________________________
Does your child attempt to involve others in play?  Yes
 No
Explain: ________________________
_____________________________________________________________________________________
Does your child engage in interactive play with other children?  Yes
 No
Explain: ______________
_____________________________________________________________________________________
Does your child attempt to involve others in play?  Yes
 No
Explain: ________________________
_____________________________________________________________________________________
Does your child engage in pretend play?  Yes
 No
Explain: ________________________________
_____________________________________________________________________________________
COMMUNICATION SKILLS
Describe your child’s spontaneous vocalization/language: _______________________________________
_____________________________________________________________________________________
Does your child respond in some way when his/her name is called? _______________________________
_____________________________________________________________________________________
Describe your child’s ability to imitate sounds, words, phrases: ___________________________________
_____________________________________________________________________________________
Describe how your child communicates what she/he wants: _____________________________________
_____________________________________________________________________________________
Does your child follow simple directions  Yes  No
If so, how consistently? ______________________
_____________________________________________________________________________________
Does your child make eye-contact?  Yes  No
If so, how consistently? _________________________
_____________________________________________________________________________________
Revised 8/10/11
Client Initials ___________
5
COMMUNICATION SKILLS (CON’T)
Does your child label items/events/actions?  Yes  No
If so, how many? When? __________________
_____________________________________________________________________________________
Does your child answer WH questions?  Yes  No
If so, how many? When? _____________________
_____________________________________________________________________________________
Does your child engage in verbal exchanges with others?  Yes  No
If so, how many? When? _______
_____________________________________________________________________________________
ACADEMIC SKILLS
Can your child perform any of the following?
Identify numbers:
Identify letters:
Complete puzzle:
Match items:
Sort colors and shapes:
Stack blocks:
Draw:
Write numbers/letters:
Identifies people:









Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes









No
No
No If so, what kind?____________
No
No
No
No
No
No
MOTOR SKILLS
Can your child imitate simple gestures (e.g., clapping, waving)?  Yes  No
Can your child imitate simple gestures using objects (e.g., banging on drum)?  Yes  No
Can your child imitate fine motor gestures?  Yes  No
Describe the child’s general gross motor abilities: _____________________________________________
Describe the child’s general fine motor abilities: _______________________________________________
SELF HELP SKILLS
Is your child toilet trained?  Yes  No
How does your child feed him/herself? ______________________________________________________
Does your child dress him/herself independently?  Yes  No
Does your child clean up after him/herself independently?  Yes  No
Revised 8/10/11
Client Initials ___________
6
BEHAVIORS OF CONCERN
Have you observed your child emit any of these behaviors?
* Self-stimulatory behaviors (examples: vocal sounds, flapping hands, lining up objects):  Yes  No
If yes, please explain: ___________________________________________________________________
* Self-injurious behaviors (examples: banging head on hard objects, eye-poking):  Yes  No
If yes, please explain: ___________________________________________________________________
* Unsafe behaviors to self (examples: running away, climbing furniture):  Yes  No
If yes, please explain: ___________________________________________________________________
* Unsafe behaviors to others (examples: hitting, throwing objects):  Yes  No
If yes, please explain: ___________________________________________________________________
* Ritualistic/Obsessive behaviors (examples: wearing same clothes every day, talks only about one topic):
 Yes  No
If yes, please explain: ___________________________________________________________________
* Other behaviors of concern: _____________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
*Please attach assessments or evaluations that may help in developing your child’s program
Revised 8/10/11
Client Initials ___________
7
INTERACT BEHAVIOR CONSULTING
Notice of Privacy Practices for Protected Health Information
Effective Date: August 11, 2011
This notice describes how medical information about you may be used and disclosed and
how you can get access to this information. Please review it carefully!
Interact Behavior Consulting is permitted by federal privacy laws to make uses and disclosures
of your health information for purposes of treatment, payment and health care operations.
Protected health information is the information we create and obtain in providing our services to
you. Such information may include documenting your symptoms, behaviors, examination and
test results, diagnoses, treatment, and applying for future care or treatment. It also includes
billing documents for those services.
Examples of Uses of Your Health Information for Treatment Purposes are:
•
A behavior analyst may use your health information to provide you with services.
•
A behavior analyst may obtain treatment information about you and record it in your client
file.
•
During the course of your treatment, the behavior analyst may need to consult with other
professionals or individuals (e.g., physicians, social workers, educators, family members
etc.,). involved in your medical care or treatment. He/she will obtain authorization to share
your personal information with these individuals.
•
Your health information may be shared with other clinical staff in the company for additional
support in developing your treatment program.
Example of Use of Your Health Information for Payment Purposes:
We submit requests for payment to your health insurance company. The health insurance
company (or other agencies/businesses helping us obtain payment) requests information from us
regarding medical care given. We will provide information to them about you and the services
provided.
Example of Use of Your Information for Health Care Operations:
We obtain services from our insurers or other business associates such as quality assessment,
quality improvement, outcome evaluation, protocol and clinical guideline development, training
programs, credentialing, medical review, legal services, and insurance. We will share
information about you with such insurers or other business associates as necessary to obtain
these services.
HIPAA Privacy Notice p. 1
August 2011
Example of Use of Your Information for Fundraising Activities:
We may contact you as part of a fundraising effort. We may use health information about you to
contact you in an effort to raise money for our company and its operations. We may disclose
health information to a foundation related to us so that the foundation may contact you in raising
money for our office/hospital. We only would release contact information, such as your name,
address and phone number, and the dates you received treatment or services at our
office/hospital. If you do not want us to contact you for fundraising efforts, you must notify our
Director in writing.
Your Health Information Rights
The health and billing records we maintain are the physical property of Interact Behavior
Consulting. The information in it, however, belongs to you. You have a right to:
•
Request a restriction on certain uses and disclosures of your health information by contacting
our office -- we are not required to grant the request, but we will comply with any request
granted;
•
Request a restriction on disclosures of medical information to a health plan for purposes of
carrying out payment or health care operations (and is not for purposes of carrying out
treatment; and the PHI pertains solely to a health care service for which the provider has been
paid out of pocket in full—we must comply with this request;
•
Obtain a paper copy of the current Notice of Privacy Practices for Protected Health
Information ("Notice") by making a request at our office;
•
Request that you be allowed to inspect and copy your health record and billing record – you
may exercise this right by contacting our office;
•
Appeal a denial of access to your protected health information, except in certain
circumstances;
•
Request that your health care record be amended to correct incomplete or incorrect
information by delivering a request to our office. We may deny your request if you ask us to
amend information that:
•
Was not created by us, unless the person or entity that created the information is no
longer available to make the amendment;
•
Is not part of the health information kept by or for the office;
•
Is not part of the information that you would be permitted to inspect and copy; or,
•
Is accurate and complete.
HIPAA Privacy Notice p. 2
August 2011
If your request is denied, you will be informed of the reason for the denial and will have an
opportunity to submit a statement of disagreement to be maintained with your records;
•
Request that communication of your health information be made by alternative means or at
an alternative location by delivering the request in writing to our office;
•
Obtain an accounting of disclosures of your health information as required to be maintained
by law by delivering a request to our office. An accounting will not include uses and
disclosures of information for treatment, payment, or operations; disclosures or uses made to
you or made at your request; uses or disclosures made pursuant to an authorization signed by
you; uses or disclosures made in a facility directory or to family members or friends relevant
to that person's involvement in your care or in payment for such care; or, uses or disclosures
to notify family or others responsible for your care of your location, condition, or your death.
•
Revoke authorizations that you made previously to use or disclose information by delivering
a written revocation to our office, except to the extent information or action has already been
taken.
•
Elect to opt out of receiving further fundraising communications from the office.
If you want to exercise any of the above rights, please make an appointment with our Director at
(510) 306-1422 to make a request in person or in writing, during regular, business hours. She
will inform you of the steps that need to be taken to exercise your rights.
Our Responsibilities
The office is required to:
•
Maintain the privacy of your health information as required by law;
•
Provide you with a notice as to our duties and privacy practices as to the information we
collect and maintain about you;
•
Abide by the terms of this Notice;
•
Notify you if we cannot accommodate a requested restriction or request; and,
•
Accommodate your reasonable requests regarding methods to communicate health
information with you.
We reserve the right to amend, change, or eliminate provisions in our privacy practices and
access practices and to enact new provisions regarding the protected health information we
maintain. If our information practices change, we will amend our Notice. You are entitled to
receive a revised copy of the Notice by calling and requesting a copy of our "Notice" or by
visiting our office and picking up a copy.
HIPAA Privacy Notice p. 3
August 2011
To Request Information or File a Complaint
If you have questions, would like additional information, or want to report a problem regarding
the handling of your information, you may contact Krista Canon, Director, (510) 306-1422.
Additionally, if you believe your privacy rights have been violated, you may file a written
complaint at our office by mailing the written complaint to 2340 Powell Street., Suite 347,
Emeryville, CA.
•
We cannot, and will not, require you to waive the right to file a complaint as a condition of
receiving treatment from Interact Behavior Consulting.
•
We cannot, and will not, retaliate against you for filing a complaint
Other Disclosures and Uses
Communication with Family
•
Using our best judgment, we may disclose to a family member, other relative, close personal
friend, or any other person you identify, health information relevant to that person's
involvement in your care or in payment for such care if you do not object or in an
emergency.
Notification
•
Unless you object, we may use or disclose your protected health information to notify, or
assist in notifying a family member, personal representative, or other person responsible for
your care, about your location, and about your general condition, or your death.
Research
•
We may disclose information to researchers when their research has been approved by an
institutional review board that has reviewed the research proposal and established protocols
to ensure the privacy of your protected health information.
Disaster Relief
•
We may use and disclose your protected health information to assist in disaster relief efforts.
Organ Procurement Organizations
•
Consistent with applicable law, we may disclose your protected health information to organ
procurement organizations or other entities engaged in the procurement, banking, or
transplantation of organs for the purpose of tissue donation and transplant.
HIPAA Privacy Notice p. 4
August 2011
Food and Drug Administration (FDA)
•
We may disclose to the FDA your protected health information relating to adverse events
with respect to food, supplements, products and product defects, or post-marketing
surveillance information to enable product recalls, repairs, or replacements.
Workers Compensation
•
If you are seeking compensation through Workers Compensation, we may disclose your
protected health information to the extent necessary to comply with laws relating to Workers
Compensation.
Public Health
•
As authorized by law, we may disclose your protected health information to public health or
legal authorities charged with preventing or controlling disease, injury, or disability; to report
reactions to medications or problems with products; to notify people of recalls; to notify a
person who may have been exposed to a disease or who is at risk for contracting or spreading
a disease or condition.
Abuse & Neglect
•
We may disclose your protected health information to public authorities as allowed by law to
report abuse or neglect.
Employers
•
We may release health information about you to your employer if we provide health care
services to you at the request of your employer, and the health care services are provided
either to conduct an evaluation relating to medical surveillance of the workplace or to
evaluate whether you have a work-related illness or injury. In such circumstances, we will
give you written notice of such release of information to your employer. Any other
disclosures to your employer will be made only if you execute a specific authorization for the
release of that information to your employer.
Correctional Institutions
•
If you are an inmate of a correctional institution, we may disclose to the institution or its
agents the protected health information necessary for your health and the health and safety of
other individuals.
HIPAA Privacy Notice p. 5
August 2011
Law Enforcement
•
We may disclose your protected health information for law enforcement purposes as required
by law, such as when required by a court order, or in cases involving felony prosecution, or
to the extent an individual is in the custody of law enforcement.
Health Oversight
•
Federal law allows us to release your protected health information to appropriate health
oversight agencies or for health oversight activities.
Judicial/Administrative Proceedings
•
We may disclose your protected health information in the course of any judicial or
administrative proceeding as allowed or required by law, with your authorization, or as
directed by a proper court order.
Serious Threat
•
To avert a serious threat to health or safety, we may disclose your protected health
information consistent with applicable law to prevent or lessen a serious, imminent threat to
the health or safety of a person or the public.
For Specialized Governmental Functions
•
We may disclose your protected health information for specialized government functions as
authorized by law such as to Armed Forces personnel, for national security purposes, or to
public assistance program personnel.
Coroners, Medical Examiners, and Funeral Directors
•
We may release health information to a coroner or medical examiner. This may be
necessary, for example, to identify a deceased person or determine the cause of death. We
may also release health information about clients to funeral directors as necessary for them to
carry out their duties.
Other Uses
•
Other uses and disclosures, besides those identified in this Notice, will be made only as
otherwise required by law or with your written authorization and you may revoke the
authorization as previously provided in this Notice under "Your Health Information Rights."
HIPAA Privacy Notice p. 6
August 2011
INTERACT BEHAVIOR CONSULTING
Name of Client: __________________________________________
Client Date of Birth: _________________________________
Notice of Privacy Practices Acknowledgement
I acknowledge that I have received a copy of the Notice of Privacy Practices with the effective
date of August 11, 2011.
_____________________________________
Signature of Client/Client Representative
______________________
Date
_____________________________________
Relationship to Client
Documentation of Good Faith Efforts
To obtain client’s acknowledgment that they received provider’s
Notice of Privacy Practices
(For use when acknowledgment cannot be obtained from the Client.)
On _____/_____/_____, the client was provided with a copy of Notice of Privacy Practices. A
good faith effort was made to obtain from the client a written acknowledgment of his/her receipt
of the Notice. However, such acknowledgement was not obtained because:


Client refused to sign.
Client was unable to sign or initial because:
_____________________________________________________________


The client had a medical emergency, and an attempt to obtain the
acknowledgment will be made at the next available opportunity.
Other reason (describe below):
_____________________________________________________________
Signature of Employee Completing Form: ______________________________________
Date Signed: _____________________
HIPAA Privacy Notice Acknowledgement
August 2011
Informed Consent and Service Agreement
I, __________________________________, as a parent or guardian,
give my consent for Interact Behavior Consulting to provide behavior
analytic services to my child, ________________________________,
in accordance with the ethical guidelines proposed by the Behavior
Analytic Certification Board (BACB). I also understand that I may
withdraw my consent and terminate treatment at anytime and for any
reason.
I understand that any information provided in this intake as well as
any information obtained at any point during the interview process or
course of treatment, is kept strictly confidential in accordance with
HIPAA regulation guidelines and the law. I understand that state laws
may require that confidentiality be broken under certain
circumstances, specifically, if I am judged by the behavior analyst to
be of danger to myself and/or others, gravely disabled, or if there is
suspected child abuse.
I understand that Board Certified Behavior Analysts are bound to strict
ethical guidelines of practice and that any issues of concern that may
arise throughout the treatment process that are out of the behavior
analyst’s area of experience may result in referrals to a more
appropriate agency or individual.
__________________________________
Signature of Parent or Guardian
______________
Date
____________________________________________________
Witness
AUTHORIZATION FOR RELEASE AND EXCHANGE OF INFORMATION
I,____________________________________, hereby authorize Interact Behavior
Consulting and the person/organization listed below to release and exchange
psychological, educational, medical, and other information about:
Client’s name: ___________________________
DOB: ________________________
Person/organization receiving/communicating information:
Name: ________________________________________________________
Address: _______________________________________________________
City: _________________________________ State: ________ Zip: _______
Phone: _________________________
I understand that this authorization is valid for the period of time in which my child is an
active client with Interact Behavior Consulting. I understand that I may see the
information that is to be sent, and that I may revoke the authorization at any time by
written, dated communication.
______________________________________
Signature
___________________
Date
______________________________________
Signature of Interact Behavior Consulting staff
___________________
Date
Relationship to client:  Self
 Parent
 Guardian
Payment Policy
I, ______________________________________________, agree to pay Interact
Behavior Consulting for all services rendered and agree to abide by the following
guidelines:
1. Payment. I understand I will receive an invoice on a biweekly basis for services
rendered me by Interact Behavior Consulting. Cash, credit or check will be
accepted for all payments due on the date indicated on the invoice.
2. Funding sources. If my insurance carrier provides financial assistance for
services, I understand I must pay the fees by the due date indicated on the
invoice and allow the insurance carrier to reimburse me for the services unless a
current authorization for insurance to cover the amount is on file. I also
understand I am responsible for any co-payment amounts due on the date
indicated by invoice. If I am receiving funding from an outside funding source or
agency, the funding source or agency will be billed directly for the services.
3. Nonpayment. If my account is over 90 days past due, I will receive a letter
stating that I have 20 days to pay my account in full. Partial payments will not be
accepted unless otherwise negotiated. Please be aware that if a balance remains
unpaid, we may refer your account to a collection agency.
4. Returned check/insufficient funds. I understand I will be charged a fee of
$35 for any returned checks.
5. Missed appointments. In the event of emergency situations, I must provide
24 hours notice to my primary contact person at Interact Behavior Consulting in
order to cancel an appointment or I will be billed for the full amount of the
session. In the event of an unexpected illness in which 24 hours notice cannot be
made, I am required to provide at least a 2 hours notice prior to the start of a
scheduled appointment in order to prevent being billed for the full session. I
understand that when a client arrives late to a scheduled appointment, the client is
billed the rate of the full appointment. Repeated failures to attend scheduled
sessions or frequently arriving late to scheduled sessions may result in termination
of services.
I have read and understand the payment policy:
___________________________________
Signature of client or guardian
______________
Date
Thank you for choosing Interact Behavior Consulting