ABA Therapy Intake

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Thank you for choosing Rowell Family Empowerment to provide Behavior Support Services through our Applied Behavior Analysis program.

We are committed to working closely with you to ensure your child's success. Please complete this intake to start the process.

*In addition to the intake packet, please send us a diagnostic report and prescription/referral for ABA services from your primary care provider.

Instructions for Completing this Intake

Please complete all sections of the intake
If any section is unclear, please contact our office for assistance
Once completed, please submit the diagnostic and prescription/referral to our office by bringing it to

Our office located at 3330 Churn Creek Road, Suite A-1, Redding
Fax it to (530) 226-5141
Email to Jennar@RFENC.org

If you have any questions about your insurance benefits, our office staff can help you verify coverage.

Included in this intake are Sections to include

Intake Form
Primary Provider/Referral Information
Parent/Guardian Questionnaire
Consent to Treatment
Insurance Information & Verification Form and Financial Agreement
Parent/Guardian, and Client Responsibilities
Cancelation Policy
HIPAA Notice of Privacy Practices
Grievance Policy
Authorization to Release Medical Records (PHI ROI)

Physician Information

Does the client have a Primary Care Physician?

Provider's Office Name:

Provider's Name:

Phone Number:

Client Information

Demographic Info

Client Information

Child First Name

Child Last Name

Child's date of birth

Gender

MaleFemale

Child's School Name

Child's qualifying category (if known)

School/Day Program (if enrolled)

Parent/Family Information

First Name

Last Name

Home Adress

City

State

Zip

County

NOTE: If no email address type NoEmail@no.com

Phone Type

Home Phone

Work Phone

Mobile Phone

You can text this phone

YesNo

Family Role

Primary Language

Ethnicity

How did you hear about us?

Availability for Sessions (Check all days and times that work for you)

Day of the Week for Session (check all available days)

Monday Tuesday Wednesday Thursday Friday

Time of Session (check all available times)

8:30 am - 10:00 am10:30 - 12:00 pm1:00 pm - 2:30 pm2:30 pm - 4:00 pm3:30 pm - 4:30 pm

Parent/Guardian Questionnaire

Client Goals and Information

What are goals you hope to achieve and/or challenges you want to address through ABA therapy?

Has you or your child previously received ABA therapy? If yes, please provide details.

What are your child's strengths and intrerests?

What is your child's communication style?

Other information about your child's development, health, or family dynamics?

Consent for ABA Treatment

This form gives our center permission to provide ABA therapy services and outlines the nature of the treatment, the procedures used, and the rights of the client and their guardians. Please review it carefully and ask any questions you may have.

Nature of ABA Treatment

ABA therapy involves the systematic application of principles of behavior analysis to improve socially significant behaviors. Treatment may include skill acquisition programs, behavior reduction techniques, and other interventions designed to address specific needs. ABA services may be provided in various settings, including the home, clinic, and community environments.

The primary goals of ABA treatment are to:

Improve communication, social, and adaptive skills.
Decrease problem behaviors (e.g., aggression, self-injury, tantrums).
Increase independence and functional abilities.
Foster participation in family and community life.

Expected Duration and Frequency of Treatment

ABA treatment offered through Rowell Family Empowerment aims to create treatment plans that can be generalized within 6-12 months. ABA sessions will not exceed two (2) consecutive hours in duration and will not occur more often than three sessions per week. Treatment plans will be regularly reviewed and updated to ensure progress, and interventions will be modified as needed to maximize progress.

Services will include:

Direct therapy by a Registered Behavior Technician (RBT) and/or Board- Certified Behavior Analyst (BCBA), caregiver training and support, and regular progress reviews and updates.

Potential Risks and Benefits:

As with any therapeutic treatment, ABA therapy may have both benefits and potential risks.

Benefits:

Improvement in communication, social skills, and independence.
Decrease in problem behaviors and more appropriate behavior patterns.
Enhanced quality of life for the child and family.

Potential Risks:

Some children may experience frustration, and/or temporary increases in problem behavior during the learning process.
The intensity of treatment may lead to fatigue for the child.
There is a possibility that some behaviors may not improve as expected.

Confidentiality

All information related to your child’s treatment will be kept strictly confidential in accordance with federal and state laws, including the Health Insurance Portability and Accountability Act (HIPAA) and California state law. This includes your child’s medical records, progress notes, and any personal information shared during treatment. Information may only be shared with authorized individuals, such as your child's healthcare providers, with your consent.

Alternatives to ABA Treatment

You have the right to choose other treatment options or refuse ABA therapy entirely. Alternatives to ABA treatment include, but are not limited to, speech therapy, occupational therapy, and medication management. You are encouraged to discuss all treatment options with your child’s healthcare provider before deciding.

Your Rights as a Parent/Guardian

You have the right to be involved in the development and review of your child’s treatment plan.
You can ask questions or request clarification about any aspect of the treatment at any time.
You may request changes to the treatment plan, and services will be adjusted accordingly if needed.
You may refuse any part of the treatment at any time without affecting your child’s eligibility for future services.
You have the right to a clear understanding of the fees and insurance billing, and any applicable costs of ABA services.

*By checking these boxes, you acknowledge that you have:

Read and understand the information provided in this Informed Consent Form.

Had the opportunity to ask question sand receive adequate answers.Been informed of the benefits, risks, and potential outcomes of ABA therapy for your child.Been informed of the alternative treatment options available.Agreed to proceed with treatment as outlined above.

Insurance Information

Insurance Acknowledgment

To begin the process of verifying your health insurance benefits, please provide the following details - a copy of your insurance card will also be required.

Insurance Company Name:

Policy Holder Name:

Policy Number:

Group Number

Effective Date of Coverage:

Member Service Phone Number:

*By checking the boxes below, I confirm that I have read and understand the financial policies outlined above and agree to be financially responsible for the services provided.

INSURANCE VERIFICATION

I understand that the center will verify my insurance coverage, but I am responsible for providing accurate insurance information.Failure to verify coverage may result in delayed therapy sessions.I understand I am responsible for notifying Rowell Family Empowerment of any changes to my insurance coverage.I agree to provide requested documents to my insurance carrier and/or Rowell Family Empowerment in a timely manner.I understand that I am responsible for any costs not covered by insurance and I may appeal any denials and seek funding from alternative sources.

CO-PAYMENTS/DEDUCTIBLES

I understand that I may be responsible for paying co-pays and/or deductible amount as determined by my insurance policy and that these rates are not set by Rowell Family Empowerment.I understand that a co-payment may be required for each session or service rendered, as specified by my insurance policy and it is my responsibility to confirm coverage with my insurance carrier.I understand any disputes regarding coverage, co-payments and/or deductibles are my responsibility and I may be required to provide documentation directly to my insurance carrier.

ACKNOWLEDGMENT OF FINANCIAL RESPONSIBILITY

I acknowledge that I have read and understood the above financial responsibilities and agree to abide by them.I understand that if there are any questions about my financial responsibilities, I can contact my insurance member services department.I have been informed of the process for verifying eligibility, and understand services may be placed on hold pending monthly verification of eligibility.

GUARDIAN AND CLIENT RESPONSIBILITIES

As a parent/guardian, your participation in the ABA program is essential. Below are the expectations and responsibilities for your involvement:

*By checking the boxes below I acknowledge that I have read and understand the parental/guardian involvement requirements outlined above and agree to actively participate in my child's ABA program. I understand that my involvement is critical to my child's progress and I will make every effort to attend caregiver training sessions, communicate with the therapy team, and implement strategies at home.

ATTENDING CAREGIVER TRAININGS

MANDATORY ATTENDANCE: I understand that attending caregiver training sessions is a mandatory part of my involvement in the ABA program. These training courses are designed to provide me with the tools and knowledge needed to support my child's progress at home and in the community.TRAINING FREQUENCY: Caregiver training sessions will be held at the time of my child's ABA therapy session. I understand I will remain on site and meet with members of the behavior team, and training may involve observing session activities, participating in interventions, and/or implementing recommended strategies.TRAINING CONTENT: Trainings will cover key concepts and techniques used in ABA therapy, including reinforcement strategies, behavior management, and communication strategies, as well as any specific goals or interventions relevant to my child's program.

PARTICIPATION IN REGULAR COMMUNICATION

PROGRESS UPDATES: I will communicate with the ABA therapy team regularly to discuss my child's progress, challenges, and any necessary adjustments to the treatment plan.PARENT FEEDBACK: I understand that providing feedback to the behavior support center staff is important for ensuring the program's effectiveness. I will provide observations and insights regarding my child's behavior and skill outside of therapy sessions.ACCESSIBLE COMMUNICATION CHANNELS: I agree to respond to calls, emails, and other communications from the ABA team in a timely manner to ensure consistent collaboration and feedback.

**Click on link to Opt into Rowell texting (LINK TO OPT IN)

IMPLEMENTING STRATEGIES AND INTERVENTIONS AT HOME

GENERALIZATION OF SKILLS: I understand that my child's success in the ABA program depends on the consistency of strategies across different environments. I will work with the ABA team to implement strategies and interventions at home, school, and in the community.DAILY PRACTICE: I agree to practice the skills and behaviors being taught during therapy sessions in my daily routine, as recommended by the therapist, to promote generalization and long-term success. I understand I may be asked to document.

CONSISTENT ATTENDANCE AND PARTICIPATION IN SESSIONS

SESSION ATTENDANCE: I understand the importance of regular attendance and therapy sessions I will make every effort to ensure that my child attends all scheduled appointments, and will schedule make-up sessions for absences exceeding10%.ON-TIME ARRIVAL: I agree to ensure that my child arrives on time for all scheduled sessions to maximize the effectiveness of treatment.RESCHEDULING: If I need to cancel or reschedule a session, I will provide advance notice per the cancellation policy.

COMMITMENT TO THE TREATMENT PLAN

UNDERSTANDING AND AGREEMENT: I acknowledge that I have reviewed the treatment plan for my child, and I agree to actively support and follow the strategies outlined by the ABA team.COLLABORATION WITH THE TEAM: I understand that my collaboration with the ABA team, including regular communication and participation, is vital for my child's success in the program.

Cancellation and Illness Policy

At Rowell Family Empowerment we understand that unforeseen circumstances, including illness, may arise, and we aim to be flexible while maintaining consistency in services. To ensure that we can effectively manage our scheduling we have established the following cancellation policy:

NOTICE REQUIREMENT: We ask that you notify us at least 24 hours in advance if you need to cancel or reschedule an appointment. This allows us to offer the appointment to another client.

NO-SHOWS: If a client does not attend a scheduled session without prior notification, it will be considered a no-show. Repeated no-shows may result in a review of service continuation.

MAKING-UP CANCELED SESSIONS: We will make every effort to accommodate rescheduling of sessions when prior notice is provided. Rescheduled appointments should be made within the same month or on a mutually agreed upon day, subject to availability.

CONTAGIOUS ILLNESS: To ensure the health of all our clients and staff, if your child or household member has one or more of the following symptoms within 24 hours of your scheduled appointment, we ask that you notify your behavior team to cancel.

A temperature of 100.4 °F (38 °C)
Persistent coughing, sneezing, runny nose, and/or congestion can spread respiratory infections such as the flu, colds. or COVID-19
A sore throat, especially when combined with fever or other symptoms, can be a sign of a contagious illness like strep throat or a viral infection.
Symptoms like diarrhea or vomiting can indicate gastrointestinal infections such as norovirus or rotavirus, which are highly contagious. You may resume scheduled appointments when you are symptom-free for 24 hours.
A rash, especially if it is new or spreading, could indicate a contagious illness such as chickenpox, measles, or hand, foot, and mouth disease.
Other communicable symptoms such as pinkeye, lice, scabies, ringworm etc.
If your child feels unusually tired, weak, or lethargic in combination with other symptoms, it could be a sign of a contagious condition. It is better for them to stay home and rest until they feel better (if you would not send them to school, please cancel their session.)

Thank you for your understanding and cooperation. Our goal is to provide the best possible service while maintaining a safe and healthy environment for everyone.

By checking the box below you are agreeing to the Cancellation and Illness Policy statement above.

I agree

HIPAA Notice of Privacy Practices

This document provides information about your rights concerning the privacy of health information and outlines how your personal health information will be used by our clinic.

I, the undersigned, acknowledge that I have received a link to the Notice of Privacy Practices of Rowell Family Empowerment of Northern Ca, which outlines how my/our medical information may be used and disclosed, as well as how I can access this information. I understand that the Notice of Privacy Practices is also available for review at any time and can be provided to me upon request.

I acknowledge that the center is required by law to protect the confidentiality of my health information and will only disclose such information with my consent, unless otherwise authorized or required by law.

Limits to confidentiality include suspected abuse or neglect, if a threat is perceived to be imminent, and/or if subpoenaed by a court.

Authorization for Use and Disclosure of Health Information

I authorize Rowell Family Empowerment of Northern Ca, and its employees, agents, and contractors to use and disclose my/my child’s protected health information (PHI) as necessary for treatment, payment, and healthcare operations.

This may include:

Sharing information with other healthcare providers for purposes related to my/my child’s treatment.
Discussing my/my child’s treatment with insurance providers for reimbursement purposes.
Coordinating care with other medical professionals or support services related to my/my child’s health.

Confidentiality and Security

I understand that Rowell Family Empowerment takes reasonable precautions to protect the confidentiality and security of my/my child’s health information, including the use of secure systems and protocols for communication.

I also acknowledge that while the center will make every effort to ensure the confidentiality of my/my child’s information, there may be risks associated with the transmission of information, such as through email or text messages.

Patient Rights Under HIPAA

I understand that I have the following rights under HIPAA:

Right to Access: I can request access to my/my child’s records and obtain a copy.
Right to Amend: I can request corrections to my/my child’s health information.
Right to Restrict: I can request restrictions on how information is shared.
Right to Confidential Communication: I can request that communications regarding my/my child’s health information be sent to a specific address or method of communication.

CONSENT FOR COMMUNICATION

*By checking each box below you agree to the terms

I consent to be contacted by the center for purposes related to treatment, billing, and appointment reminders. These communications may include phone calls, text messages, or emails.I agree to receive texts from Rowell Family Empowerment of Northern California to my mobile number. Message and data rates may apply. Text STOP to unsubscribe from messages at any time. By subscribing, you agree to get text messages from Rowell about services we provide.

I consent to receiving email communications related to my/my child’s treatment.

ACKNOWLEDGMENT OF RESPONSIBILITY

*By checking each box below you agree to the terms

I understand that it is my responsibility to inform Rowell Family Empowerment of Northern CA, of any changes to my contact information or health condition that might affect the care or services provided.I acknowledge that I have read and understand the information provided above regarding HIPAA privacy and confidentiality practices and consent to the use and disclosure of my/my child’s health information as described.

COMPLAINT POLICY FOR ABA SERVICES PROVIDED BY BCBA OR RBT

This policy outlines how clients can file complaints regarding the ABA services provided by a Board-Certified Behavior Analyst (BCBA) or Registered Behavior Technician (RBT).

Clients are protected from retaliation for filing complaints and all complaints will be handled with confidentiality and professionalism.

Step 1: Direct Communication

First, try to discuss the concern directly with the BCBA or RBT involved to resolve the issue informally. This can be done face-to-face, or via email, phone call or text message.

Step 2: Formal Complaint

If the issue is not resolved, submit a written complaint to the Program Director

The complaint should include:

Your name, contact details, and role.
A description of the concern and relevant details (e.g., dates, examples).

Step 3: Acknowledgment

The Program Director will acknowledge receipt of the complaint within two (2) business days.

Investigation and Resolution:

The grievance officer will investigate the complaint and work to resolve the issue. A response will be provided within five (5) business days of acknowledgement, and if the client is dissatisfied with the outcome, they may request further review and/or contact the Behavior Analyst Certification Board (BACB).

Contacting the BACB:

If a client believes the BCBA or RBT has violated the professional standards, they can file a complaint directly with the BACB.

BACB Contact Information:

Website: www.bacb.com 
Behavior Analyst Certification Board, 7950 Shaffer Parkway,Littleton, CO 80127

PROHIBITION ON REDISCLOSURE
OF CONFIDENTIAL INFORMATION

This notice accompanies a disclosure of information concerning a client in alcohol/drug treatment, made to you with the consent of such client. This information has been disclosed to you from records protected by federal confidentiality rules (42 C.F.R. Part 2). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

Next Steps:
Submit this completed intake.
Our team will verify your insurance benefits.
We will schedule an initial assessment meeting and observation.
Your Behavior Analyst will create a customized treatment plan.
Once approved, we will begin scheduling on-going therapy sessions.
Questions or Concerns?

If you have questions about this intake packet, your insurance, or the services we offer, please contact our office at (530) 226-5129. Our team is here to assist you!

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