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