New Client Intake Form If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Parent/Guardian Information Parent / Guardian 1 Name * Primary Street Address Email * Phone Number * Marital Status Parent / Guardian 2 Name Primary Street Address Email Phone Number Marital Status Client’s Information Client's Name Primary Street Address Date of Birth Client's Social Security Number Phone Number Regional Center Service Coordinator Availability for Sessions (please fill in days and times- Ex: 3-6 pm, Mon/Wed/Fri) Monday Tuesday Wednesday Thursday Friday Insurance Information A copy of the insurance card will be required with this packet. Primary Insurance Name of Insurance Company Name of Policyholder Social Security Number Date of Birth Policy Holder’s Relationship to Client Insurance Address Phone Number Member ID Group Number Secondary Insurance Insurance. We participate in many insurance plans. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage. Copayments and deductibles. All co-payments, deductibles and/or co-insurance must be paid by the 15 tth of the month following service provision. The co-pay is the portion of your visit that your insurance company requires you to pay. This amount is not determined by Best Behavior, LLC. This arrangement is part of your contract with your insurance company. Please pay your co-payment in a timely manner. A co-pay invoice will be mailed to each client at the end of each month. There is a $20 Non-Sufficient Fund charge for all checks returned by your bank. Proof of insurance. We must obtain a copy of your valid insurance to ensure proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you will be responsible for the balance of a claim. Claims submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract. Services may be put on hold or terminated if the insurance company denies the service or claims go unpaid more than 30 days. Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you. Nonpayment. If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your 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 and you and your immediate family members may be discharged from this service. Practice Policy It is your responsibility to notify this office of any changes of information, including name change, change of address, phone numbers and insurance. We have a very specific protocol for insurance authorizations/referrals. If your insurance company requires a referral or pre-authorization, please ask for the protocol. We do not do retroactive authorizations. You must follow our protocol for authorization/referral numbers. We will file your insurance if we are contracted with your insurance company. Any balance unpaid by your insurance company, or if your balance is outstanding for thirty (30) days, will be your responsibility. You will be responsible for any disputed claims. If/when the claim is paid, you will be reimbursed within thirty (30) days. Any disputes about coverage or benefits are your responsibility and are between you and your insurance carrier. If you have questions regarding coverage/payment, you must direct those inquiries to your insurance carrier. AUTHORIZATION TO RELEASE INFORMATION/PAYMENT OF INSURANCE BENEFITS: I hereby authorize Best Behavior, LLC to furnish my insurance carrier any information acquired in the course of my evaluation or treatment necessary to complete my insurance forms. Also, I hereby assign to Best Behavior, LLC all payments for services rendered. In the event that my insurance company does not pay for services rendered, I understand that I am fully responsible for all payments due. Policy Holder’s Signature that the above information is correct: Policy Holder’s Signature that the above information is correct Signature date Medical Information A copy of the diagnostic evaluation and a prescription from the physician for ABA services will be required with this packet. Name of physician Physician address Physician phone Preferred Hospital(s) Does your child have any current health conditions? If so, please explain below: Please list any medications your child is currently taking, both prescription and over the counter Best Behavior does not offer on-call coverage for ABA services and programs on a 24-hour basis. Clients may contact Best Behavior staff with questions or comments by telephone or email. Concerns may also be directed to Best Behavior’s owners/partners: Adam Yates, Jenna Ryan, or Rebekah Catalano. Confidentiality Policy I understand that all information I provide during the provision of services by Best Behavior will be handled with strict confidentiality. No information, verbal or written, will be released to other agencies or individuals without my written consent. Best Behavior maintains client confidentiality in compliance with HIPAA. I understand the limitations to confidentiality, including: Abuse or neglect of a minor or individual with disabilities must be reported to Child Protective Services for investigation. If a threat is perceived and it is felt the threat will be carried out, Best Behavior staff have an ethical obligation to warn the potential victim. If subpoenaed by the court, and required to provide information regarding training, clients, or staff testimony, Best Behavior staff are legally bound to provide that information. Cancellation Policy Families must contact the cancellation line at (530-255-4299) in order to record any cancelled session. Due to the medical needs of our clients, we require that parents/caregivers cancel therapy sessions for the following reasons: Fever at or above 100F° Vomiting Sinus infections/colds with yellow, green mucous Conjunctivitis (pink eye) Lice Strep Throat Chicken Pox, Measles, Mumps, RSV, Rubella, Mononucleosis Flu-like symptoms Viral infections, rashes, or any other contagious illness Your child may begin receiving services after an illness within the below listed time periods: ● 24 hours – Must be symptom-free and receiving the necessary medications for: vomiting, fever, sinus infections, and colds. ● 48 hours – After receiving medical treatment with antibiotics for: Strep throat and conjunctivitis. ● 72 hours – After receiving medication treatment and having no live lice; also, following maintenance treatments as indicated on product label. ● Viral infections such as hand, foot, and mouth disease may be more subjective in the cancellations due to the highly contagious nature of viruses. Staff will work with families to resume services as quickly as staff and the family feel is appropriate Best Behavior LLC 1768 West Street Redding, CA 96001 ● Physician's Release – Must obtain after chicken pox, measles, mumps, RSV, rubella, and mononucleosis. (If for any reason your child is admitted to the hospital, you must provide a release from the Physician stating that it is okay to resume therapy, and/or resume limited therapy; before services can be continued. Best Behavior staff may cancel sessions if they also exhibit the symptoms listed above. Staff will follow the same cancellation time periods. Best Behavior will make every attempt to reschedule any sessions cancelled by staff. Families are expected to make every attempt to reschedule any sessions cancelled by the family. Developmental History Has your child ever had ABA, speech/language, Parent Infant Program or occupational therapy, currently or in the past? If so, what type of therapy? When? Where? Reason(s) for therapy Goals achieved? School Age History School Age Level / Teacher Describe your child’s typical grades / reports from the school What concerns do you or the school have regarding school performance? Regarding attention/concentration? Regarding work habits? Regarding behavior? Does your child receive special education services at school? What services are received? Does your child have an IEP? What is the date of the last IEP? Is there any additional school related information that you feel would help with evaluating the child? Areas of Concern (check all that apply) Picky eater Difficulties eating Refusal to obey Limited toy play Aggression Self-Injury Poor eye contact Sensitive to touch, smells, tastes Unable to dress self Limited social relationships Doesn’t follow instructions Limited vocabulary Difficulty sleeping Echolalia Runs from supervision Difficulty answering questions Fixation on toys, electronics Impulsivity Poor hygiene Stimming Other concerns/additional information Guidelines of Effective Programming: Family A primary caregiver over the age of 18 years must be in the home throughout the duration of programming sessions. If a primary caregiver is not available, the family must cancel the session. Except in the case of an emergency, the behavior analyst must receive all cancellation phone calls no later than ONE HOUR prior to the start of the session. The caregiver is expected to reschedule any cancelled sessions within the month whenever possible. If the caregiver cancels more than 10% of the sessions held in one month and do not reschedule the sessions, a meeting will be held to determine the future of programming. Failure to call the behavior analyst to cancel the session will be documented. More than two cancellations without notification will result in a meeting to determine the future of programming. Caregivers are expected to fully participate in all programming sessions by: Observing the interactions of the behavior analyst with the client Practicing recommended strategies Accepting feedback from the behavior analyst Asking questions to the behavior analyst regarding programming, concerns regarding strategies, and/or additional problem behaviors Report to the behavior analyst regarding strategy implementation outside of programming sessions Provide data to the behavior analyst and discuss as needed Outside of programming hours, caregivers are expected to: Take data as directed by the behavior analyst Apply recommended strategies and interventions Contact the behavior analyst regarding any significant changes in the client’s behavior prior to the next session If programming includes trips into the community, the caregiver is expected to provide: Transportation for the client (and behavior analyst if the car ride is an area of concern) Any necessary materials for the community outing (i.e. grocery list, money) All programming sessions will occur in the natural environments of the client. Caregivers will be expected to share with the behavior analyst all relevant information regarding potential sites of programming (i.e., mother’s home, grandparents’ home, father’s home). All primary caregivers are expected to participate in programming. Level of participation will be agreed upon in an initial meeting with all caregivers and the behavior analyst at the start of programming. All individuals involved in programming will be expected to maintain a professional relationship. No relationship outside the direct relationship between the behavior analyst and the client will be tolerated. Parents/Guardians/Caregivers will be expected to refrain from engaging in conversations of a personal or private nature with the behavior analyst. If at any time the professional relationship is compromised, Best Behavior reserves the right to initiate a meeting to discuss the future of programming. It is considered unethical for the behavior analyst and any Best Behavior staff to accept gifts from clients including meals, presents, gift cards, money and/or any other offering which can be misconstrued as exchanging goods for services. If at any time the caregiver/client wishes to express concern regarding the professionalism or ethical standards of the behavior analyst, they have the right to complain to the BACB. Information regarding the complaint process is provided on the program plan document. Consumption of alcohol, cigarettes, marijuana, or any other drugs during programming hours will not be tolerated. Substance abuse of any nature during the provision of services will result in termination of the immediate programming session and the Best Behavior staff will initiate a meeting to determine the future direction of programming. The natural environment of the client (home, residential center, community setting, etc.) is the workplace environment of the behavior analyst. As such, the programming environment falls under the guidelines of AB-13 Fact Sheet prepared by the California Occupational Safety and Health Administration (CAL OSHA). Any conditions which may pose a health risk within the home environment (such as black mold, lead paint exposure, flea or cockroach infestations) may result in termination of the immediate programming session and the Best Behavior staff will initiate a meeting to determine the future direction of programming. Grievances Policy Situations may occur where an individual believes that the fair and consistent application of a policy affecting him or her has not been followed. In most cases, Best Behavior, LLC expects the individual will be able to resolve any complaints directly. No individual shall be subjected to discrimination or adverse treatment for participating in a grievance procedure. When a recent or continuing problem has not been resolved in a timely manner, the following procedure will occur: The grievance procedure consists of two steps: (1) Step I–Informal and (2) Step II–Formal. Each step has its own procedures, as set forth below. Step I - Informal 1 If the individual feels uncomfortable directly communicating with the person in question, the individual will communicate with another partner of Best Behavior, LLC. The individual should explain the nature of the problem and the solution being sought. The partner will respond in writing within two business days. If the situation is not resolved, the individual will submit a written letter of complaint to Best Behavior, LLC. The letter should include the nature of the problem, previous communication with any partner of Best Behavior, LLC, and/or a proposed solution. Best Behavior, LLC will contact the Service Coordinator within one business day to request a meeting with all parties involved. Step II - Formal 3 If the situation is still unresolved, the individual may submit a complaint form to the Behavior Analyst Certification Board (BACB). All complaints must be filed using the specified complaint form found on the BACB website: http://www.bacb.com/index.php?page=56 Completed complaint forms can be submitted electronically via the BACB website or mailed to the following address: Behavior Analyst Certification Board, Inc. Disciplinary Matters 7950 Shaffer Parkway Littleton, Colorado 80127 Guidelines of Effective Programming: Best Behavior Admission into ABA services will be available to children, adolescents, and adults with or without a diagnosis based on the need/desire to modify established behaviors. Certain provisions may apply in regard to diagnosis if someone is seeking funding for the service through a third party, such as private insurance or private pay. When needed, Best Behavior will provide the client/family with contact information for other professionals who may be better able to assist with the needs of the client if Best Behavior is unable to meet specific treatment needs. Services will focus on the development and implementation of a functional behavior assessment and an ABA treatment plan. ABA services will be provided by a Board Certified Behavior Analyst (BCBA), Board Certified Assistant Behavior Analyst (BCaBA) or a highly trained Behavior Consultant and Behavior Technician under the supervision of a BCBA. Best Behavior provides ABA services based on the client’s current level of individualized needs. The treatment plan will structure antecedent and consequence based strategies that are skill-based, functionally equivalent, and non-aversive. Interventions will focus on reducing problematic behavior and increasing functionally related skills. Behavioral assessment results are available to the client and/or family, and a preliminary treatment plan meeting will be scheduled with the client and ABA professionals to review the proposed service type(s), treatment plan goals and objectives, recommended duration and length of treatment, and an exit plan for the client. Upon exiting treatment, recommendations will be provided as a way to support continued progress or address persisting concerns. The contents of both the assessment and treatment plan will be explained to the client and/or family, and Best Behavior staff will willingly answer any related questions about the assessment or proposed service. Best Behavior understands that this information is confidential, and will abide by established confidentiality policies and procedures. In addition to direct ABA treatment, ABA services also include training and ongoing consultation in the principles of applied behavior analysis as they pertain to the client’s treatment plan with family, educators, and any related service providers as requested by the family. Best Behavior will obtain releases of Information prior to communicating with any related providers. All lesson materials, reports, and data collected (records) as part of service provision are considered the property of the parent/guardian. The use of these materials by the parent/guardian will not be restricted in any manner. All HIPAA confidentialities procedures will be adhered to in retaining records. Families may request copies of any/all records pertaining to the client for up to seven years from the date this document is signed. Transition Plan In the event the family moves to a new residence in which Best Behavior, LLC is not available to provide services, the following protocol will be implemented to transfer services to another ABA provider in order to minimize any potential lags in service and prevent the development of additional problem behavior: Best Behavior, LLC will aggregate and graph all data Update the Behavior Intervention Plan with current antecedents, proactive and reactive strategies as well as reinforcement schedules Prior to updating the treatment plan the behavior consultant and behavior analyst will assess in the home and community current skill levels targeted in the treatment in order to generate an exit report The behavior analyst will update and transition the current treatment report to an exit report When the family has contacted a new provider Best Behavior will contact the new provider and set a meeting in order to coordinate the transfer of data and documents and explain any unclear strategies It will be the parents’/guardians’ responsibility to contact their doctor in order to generate a new, current referral for ABA services to provide to the new ABA provider It will be the doctor’s responsibility to fax/send the referral to the new provider. Exit Plan The criteria for exiting the ABA program provided by Best Behavior, LLC are as follows: The client meets all objectives recommended by Best Behavior, LLC in the time period authorized by their insurance and . . . The clients parents/guardians continue to independently implement the interventions recommended by Best Behavior, LLC outside of programming hours and... The clients family indicates that in-home ABA services are no longer needed for their child, either directly or through excessive cancellations, or . . . The client continuously displays stunted to no progress or adaptive response to the program implemented by Best Behavior and . . . The clients’ parents/guardians continuously require reminders and prompts to implement the interventions recommended by Best Behavior, LLC outside of programming hours and/or . . . The clients’ parents/guardians refuse to implement the interventions recommended by Best Behavior, LLC outside of programming hours and/or . . . The clients’ parents/guardians continuously cancel more than 50% of planned sessions and/or . . . The clients’ parents/guardians continuously consume alcohol or illegal drugs during programming sessions despite reminders by Best Behavior, LLC to abstain from doing so, and/or .. . The clients’ parents/guardians continuously do not have an 18-year-old or older family member or friend present during sessions per Best Behavior, LLC policy