Welcome to Eclipse Therapy...Welcome to Eclipse Therapy Dear Family, Star.ng therapy for your child...

WelcometoEclipseTherapy

DearFamily,

Star.ngtherapyforyourchildcanbeexci.ngaswellasoverwhelming.Wewillworktogethertoachievethegoalsyousetforyourchild.Includedinthispacketareasignificantnumberofforms.Pleasefeelfreetoaskmeanyques.onyouhaveviaemailorphone.

Iamexcitedtoembarkonthisjourneywithyourfamily.

Sincerely,Rosalie

1

AnOverviewofEclipseTherapyLLC’sApproach

Mission:

Toensurethateveryfamilyhastheopportunitytoenjoythesimplepleasuresoflife:apeacefulfamilydinner,aquietgameofcards,amovienightout,oranevent-freetriptothegrocerystore.Eclipsewillprovideconsistentandexcep.onalbehavioranaly.cservicestochildrenwithdisabili.es.Servicesareprovidedtoop.mizethechild'sprogresstowardstheirindividualizedgoal.

Purpose:ThecornerstoneofEclipseTherapyistheunderstandingthatanyimpairmentordisabilitycanhaveadebilita.ngeffectonanindividualandthefamily.Withsteadfastloyalty,Eclipsewillstrivetenaciouslytoincreasethechild’sabili.esinanefforttoimprovethefunc.oningofthechildandfurthermoreincreaseharmonywithinthefamily.

Ourapproachtoworkingwitheachchild:

• Isindividuallytailoredtomeeteachchild'suniqueneeds• Isop.mizedtoensureyourchildisgainingskillsasquicklyaspossible• Isbasedonthemostcurrentresearch

Ourprogramingforau.smaddressesthemajorissuescommoninau.sm:

• Understandingandusinglanguage• Buildingbroadersocialskills• Communica.ngwithandrela.ngtopeers• Buildingageappropriateandsymbolicandplayskills• Buildingemo.onalregula.onskills• Increasingflexibilityandreducingrigidity• Increasingconceptualthinkingandcogni.veskills

Ourprogramingforchildrenwithotherdisordersisindividualtailoredbutwillincludetheseessen.alskills:

• Buildingemo.onalregula.onskills• Increasingdistresstolerance• Increasingcommunica.veabili.es• Increasingconceptualthinkingandcogni.veskills

EclipseTherapy’strainedtherapistsworkone-on-onewitheachchildcloselymonitoringresponsesinordertomatchthedifficultyofthematerialandmethodofinstruc.ontothechild'sabilitylevelandrateoflearning.Allourtherapistsholdatleastahighschooldiploma,haveextensivetrainingspecificallyinresearchsupportedtreatmentsforau.smspectrum

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disorders,behaviordisorders,andtheprincipalsofAppliedBehaviorAnalysis.Supervisionofeachchild'sprogramisprovidedbyoneofourBCBAwithregularprogressreviews.

Inaddi.ontotheindividualABAprogram,parenttraining,programstoaddressproblembehaviors,andarangeofbehavioranaly.cservicesareofferedthroughoutoursessions.Ourfocusisonhelpingyourchildgainskillsthatarecri.caltoyourfamilyandtheirfunc.oning.

Weprovidebehavioralassessments,parent&stafftraining,programsupervision,andqualityinhome/schoolABAprograming.Eachofourprogramsupervisorsisboardcer.fiedbytheBehaviorAnalysisCer.fica.onBoard.

Pleasecall720-339-1309forfurtherinforma.onorclarifica.on.

Instruc=onsforthispacketofinforma=on

Thispacketisratherlengthy,butitwillhelptheEclipseteambe^erunderstandyouchildandtheskillstheyneedtoacquireormaladap.vebehaviorsweneedtohelpreduce.Pleasebeasdetailedasyoucan.IfsomethingdoesnotapplytoyourchildpleasewriteNA.

YoucanfilloutthispacketusingaPDFfillerorprintandhandwrite.

Pages4-11and36inthisdocumentrequireyoursignature.Signaturesonthesepagesarenecessarytobegintreatment

Pleasereturnthispacketeitherbyemail,postalmail,orhanddelivertoyourchild’ssupervisor.Thesedocumentsmustbesubmi^edbeforetreatmentcanbegin.

Welookforwardtoworkingwithyourfamily!Pleasedonothesitatetocalloremailwithanyques.onsorconcerns.

3

ConsenttoTreat

I,theundersignedparent,personhavinglegalcustodyorguardianship/authorizedcareproviderof__________________________________(the“minor”),doherebyauthorizeRosalieByrdPrendergast,MSBCBA,ofEclipseTherapyandanyofthebelowEclipseteammembers,LLCtoprovideand/orsupervisebehavioralhealthservices.Suchservicesmayinclude,butarenotlimitedtoBehavioralAssessment,BehavioralTreatment,andCounselingServices.Iunderstandthisauthoriza.onmayberevokedinwri.ngatany.me.

EugeniaLogvinova,MedBCBA

KatherineThomas,MSBCBA

AmandaMontoya,MSBCBA

TimothyMullins,MFTC

BritneyBonner,MFTC

DamianYoung,LMFT

KristyO’Brien,BCABA

Mandatorydisclosureforeachclinicianavailableuponrequest.Ifforanyreasonyouneedto

file a complaint or grievance below is informa=on to do so. At Eclipse we value your

partnershipandhopethatyouwillcometouswithanyconcernsthataraiseandprovideus

anopportunitytosolvetheproblem.

a. TheColoradoDepartmentofRegularlyAgencieshasthegeneralresponsibilityofregula.ngtheprac.ceoflicensedpsychologists, licensedclinicalsocialworkers, licensedprofessionalcounselors, licensed marriage and family therapists, cer.fied school psychologist, andunlicensed individuals who prac.ce psychotherapy. The agencywithin Office of LicensingUnlicensedPsychotherapist1560Broadway,Suite1350Denver,CO80202,(800)811-7648.

b. Many of us are also regulated by the Behavior Analyst Cer.fica.on Board. They can bereached at Behavior Analyst Cer.fica.on Board 2888 Remington Green Lane, Suite CTallahassee,FL32308850-765-0905

MandatoryDisclosureStatement

1. NameofTherapists:RosalieByrdPrendergast,MSBCBAEugeniaLogvinova,MedBCBAKatherineThomas,MSBCBAAmandaMontoya,MSBCBATimothyMullins,MFTCBritneyBonner,MFTC

Client/Parent/Guardian Signature Date

4

DamianYoung,LMFTKristyO’Brien,BCABA

2. Degrees:RosaliePrendergast,MSBCBA:BA,UniversityofNorthernColorado,2004

MS,NovaSoutheasternUniversity,2009 BoardCer.fiedBehaviorAnalyst,2009 UnregisteredPsychotherapist#12185,2010

3.AgenciesIreportto:c. TheColoradoDepartmentofRegularlyAgencieshasthegeneralresponsibilityofregula.ng

theprac.ceoflicensedpsychologists, licensedclinicalsocialworkers, licensedprofessionalcounselors, licensed marriage and family therapists, cer.fied school psychologist, andunlicensed individuals who prac.ce psychotherapy. The agencywithin Office of LicensingUnlicensedPsychotherapist1560Broadway,Suite1350Denver,CO80202,(800)811-7648.

d. Many of us are also regulated by the Behavior Analyst Cer.fica.on Board. They can bereached at Behavior Analyst Cer.fica.on Board 2888 Remington Green Lane, Suite CTallahassee,FL32308850-765-0905

4.ClientRightsandImportantInforma.on:

a. You are en.tled to receive informa.on from me about my methods of therapy, thetechniques I use, the dura.on of your therapy (if I can determine it), andmy fee structure.Pleaseaskifyouwouldliketoreceivethisinforma.on.

b.Youcanseekasecondopinionfromanothertherapistorterminatetherapyatany.me.

c.Inaprofessionalrela.onship(suchasours),sexualin.macybetweenatherapistandaclientis never appropriate. If sexual in.macy occurs, it should be reported to the State Board ofPsychologistExaminers.

d.Generally speaking, the informa.onprovidedby and to a client during therapy sessions islegally confiden.al if the therapist is a cer.fied school psychologist, a licensed clinical socialworker,a licensedmarriageand family therapist,a licensedprofessionalcounselor,a licensedpsychologist, or an unlicensed psychotherapist. If the informa.on is legally confiden.al, thetherapistcannotbeforcedtodisclosetheinforma.onwithouttheclient’sconsent.

e.Thereareexcep=onstothegeneralruleoflegalconfiden.ality.Someoftheseexcep.onsarelistedintheColoradostatutes(seesec.on12-43-218,C.R.S,inpar.cular).Forexample,Iamrequiredbylawtoreportchildabuse.Thereareotherexcep.onsthatIwilla^empttoiden.fytoyou,iffeasibleatthe.me,assitua.onsariseduringtherapy.


5

Non-Discrimina=onPolicyStatement

ItisthepolicyofEclipseTherapytoprovideservicestoallpersonswithoutregardtorace,color,na.onalorigin,religion,sex,age,ordisability.Nopersonshallbeexcludedfrompar.cipa.onin,orbedeniedbenefitsof,andservice;orbesubjectedtodiscrimina.onbecauseofrace,color,na.onalorigin,religion,sex,age,ordisability.

Complaintofdiscrimina.onpolicyandprocedure:thispolicystatementcomplieswithCivilRightsAct,TitleVI(45CFRpart80.7B)andsec.on504oftheRehabilita.onActof1973(45CFRpart84.7b.Ifyoufeelthatyouhavebeendeniedabenefitorservicebecauseofyourrace,color,na.onalorigin,age,sex,disability,orreligionyoumayfileaComplaintofDiscrimina.onwiththefacilityadministratorofEclipseTherapy,eitherverballyorinwri.ng.Awri^enresponsewillbeissuedtoyouwithin21daysofthecomplaintno.ce.

Youmayalsofileacomplaintwithanexternalagency.Ifyouchoosetofileyourcomplaintinwri.ng,youmustincludeyourname,address,telephonenumber,andabriefdescrip.onofwhatoccurredwhichledyoutobelieveyouwerediscriminatedagainst.Ifyouneedassistance,thefacilityadministratorofEclipsetherapywillbeabletoassistyou

Youmayalsofileacomplaintofdiscrimina.onbycallingorwri.ngtheDepartmentofRegulatoryAgencies(DORA)DivisionofCivilRightsat(303)894-2997or1560Broadway#1050,Denver,CO80202

Pleasesigninreceiptofthispolicy.


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2091KerrGulchRdEvergreen,CO80439

720-339-1309AUTHORIZATIONTORELEASEINFORMATION

ClientNameDOB:

StreetAddress:City/StateZIP

IunderstandthisreleaseisvoluntaryandappliestoallprogramsandservicesoperatedundertheauspicesofEclipseTherapyLLC.Iunderstandthatmypersonallyiden-fiableinforma-on(PII)maybeprotectedbythefederalrulesforprivacyundertheFamilyEduca.onalRightsandPrivacyAct(FERPA),theHealthInsurancePortabilityandAccountabilityAct(HIPAA),and/orotherapplicablestateorfederallawsandregula.ons.IunderstandthatmyPIImaybesubjecttore-disclosurebytherecipientwithoutspecificwriênconsentofthepersontowhomitpertains,orasotherwisepermiêd.Ialsounderstandthattherecipientmaynotcondi.ontreatment,payment,enrollmentoreligibilityonwhetherIsignthisform,exceptforcertaineligibilityorenrollmentdetermina.ons.IunderstandthatImayrevokethisauthoriza=onat

any=mebyno=fyingEclipseTherapyLLCinwri=ngbutifIdo,itwillnothaveanyeffecton

anyac=onstakenbeforereceiptoftherevoca=on.

IherebyauthorizeEclipseTherapyLLCto(checkallthatapply):

❒Exchangewith❒Releaseto❒Obtainfromthepar=esIhaveindicatedbelow

IherebyauthorizeEclipseTherapyLLCtoexchange/release/obtaininforma=on:

❒Verballyonly❒Inwriênformonly❒Bothverballyandinwri.ng

Organiza=onorIndividualreceiving/communica=ngtheinforma=on:

NameofOrganiza=on/Individual

AddressCity,StateZipPhone

Descrip=onofinforma=ontobeexchanged/released/obtained: ❒Educa.onrecords❒Evalua.on/assessment/eligibilityrecords❒Medicalrecords❒Other

❒Clinicalrecords(includingbehavioranaly.c,psychological,physical,occupa.onal,andspeechtherapiesDura=onofrelease(checkone):

❒Thisreleasewillremainineffectfortwo(2)years,unlessotherwises.pulatedorrevokedinwri.ng.

7

❒From (MM/DD/YYYY)To(MM/DD/YYYY)Thepurposeifthisreleaseis:

FeeSchedule

BehavioralConsulta=onwithRosalieByrdPrendergast,MSBCBA,EugeniaLogvinova,Med

BCBA,KatherineThomas,MSBCBA,AmandaMontoya,MedBCBA,:

$140perhourplus$40perhourtraveledaccordingtoGoogleMaps.InHome/SchoolBehaviorTherapyMasterslevelclinician:

$120perhourplus$0.555permiletraveledroundtripaccordingtoGoogleMaps.InHome/SchoolBehaviorTherapywithRBTLevelClinicianPursuingCer=fica=on:

$85perhourplus$0.555permiletraveledroundtripaccordingtoGoogleMaps.InHome/SchoolBehaviorTherapywithRBTLevelClinician:

$50perhourplus$0.555permiletraveledroundtripaccordingtoGoogleMaps.Addi=onalChargesapplyingtoallservices:

Theseservicesmaybenecessaryforyourprogramandarebilledatyourclinician’shourlyrate.o Phoneconsulta.onlas.ngmorethan15minutes.o Wriêndocumenta.on(includingprogressreportsandotherformsofwriên

communica.on)requiringmorethan15minuteso Emailmessagesrequiringmorethan15minutes.o Wriênorverbalcommunica.onwith3rdpartypayers(includinginsurancecarriers,

CommunityCenteredBoards,etc.)requiringmorethan15minutes.o Crea.onofindividualizedtherapymaterialssuchas,butnotlimitedtobooksorstories

requiringmorethan15minutes.o Recordreviewrequiringmorethan15minutes.o Otherservicesaclientmayrequestrequiringmorethan15minutes.

PleaseSigninyouunderstandingoftheFeesChargedbyEclipseTherapyLLC.


Printed name of the guardian


8

Tom Prendergast

PaymentPolicy

EclipseTherapyLLCstrivestoofferthehighestqualityofcare.Neverwillyourcarebecon.ngentonyourinsuranceorwaivercoverage.Considerablecarehasbeentakentodetermineourrates.Wewanttoassureyouthatourchargesaccuratelyreflectthecomplexityofcarerenderedandtheskillandexper.serequiredforop.maltreatment.Ourfeesarecomparabletothoseofotherhighlyqualifiedspecialists.Whetheryouhavepurchasedinsuranceonyourown,youremployerhasprovidedittoyou,oryouhavequalifiedforamedicaidwaiver,youarefortunatetohaveitandwewillgotheextramiletohelpyoumaximizeyourbenefitsprovidedbyyourspecificplanorwaiver.Asacourtesytoyou,wewillfilewiththoseplanstowhichwehavebeenadmiêdasaprovider(InNetwork)andwhenrequestedandwehavenotbeenadmiêdasaproviderwillcompletethestandardCMS1500claimformforyoutoseekreimbursementthroughyourinsurer.Whenaserviceiscovered,yourinsurancecompanyusuallyonlypaysapercentageofthefee,andthisvariesfromcarriertocarrierandplantoplan.Yourinsuranceisnotdesignedtopaytheen.recostoftreatment,butitisintendedtohelpcoveracertainpor.onofthecost.

Pleaseremember,however,thefinancialobliga.onforourservicesarebetweenyouandEclipseTherapy,andisNOTbetweenEclipseTherapyandtheinsurancecompany.

Forclientschoosingtoprivatepayforservices,youwillbebilledmonthlyviaourQuickBooksonlineaccoun.ngsystem.Youwillreceiveabillbetweenthe1stand4thofthemonthfollowingservices.Paymentfortheseservicesisdueback30daysfromreceiptoftheinvoicefromEclipseTherapyLLC.

Paymenttoourofficeisnotcon.ngent,nordependentuponyourinsurancecompany.Allaccountbalancesmustbesa.sfiedwithin60daysofthedateserviceswerebilled,aterthat.mearebillingfeeof$10.00maybechargedtoyouraccount.Ifyouhaveanyques.onsregardingourfinancialpolicy,pleasedonothesitatetodiscussthemwithus.

Weacceptcash,check,andbanktransfersviaQuickBooksonline.

IunderstandandagreethatIamresponsibleforthepaymentofallchargesincurredregardlessofanyinsurancecoverageorotherplansavailabletome.Addi.onally,Iunderstandandagreetopayanyandallcollec.onscostsand/oraôrney’sfeesifanydelinquentbalanceisplacedwithanagencyoraôrneyforcollec.on,suit,orlegalac.on.Ialsoacknowledgethatconfiden.alityiswaivedinmaêrsinvolvingcollec.onsandthesharingofinforma.onsufficienttopursuerecoveryofdebtsowed.


9

UsingWaiverServices

**Pleasefilloutareleaseofinforma.onforustocontactyourcasemanager**

Pleasenotethatwecannotbeginservicesun.lwehaveAuthoriza.oninwri.ngfromyourCaseManager.

Ifyouwouldliketobeginservicesonaprivatepaybasispriortoapprovalpleasesignbellow.

Pleasesigninunderstandingthatifyouschedulesessionthatgooverthenumberofhoursthatyouhaveapprovedthroughyourwaiveryouwillbebilledatprivatepayrates.

Type of Waiver

Community Center Board

Case Manager Name

Case Manager Email

Case Manager Supervisor




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UsingInsurance

*******InsurancecoverageusuallyrequiresadiagnosisofAu=sm********

Pleasea^achapictureofthefrontandbackofyourcard.

Child’sName

DateofBirth

Child’sAddress

Child’sSS#

PhoneNumber

InsuranceCompany

Insurancecompanyphonenumber

GroupNumber

PolicyNumber

PlanType

PolicyHolder’sName

PolicyHolder’sDOB

PolicyHolder’sSSN

PolicyHolder’sEmployer

11

HIPAAEmailConsent

VERYIMPORTANT!PLEASEREAD!

• HIPAAstandsfortheHealthInsurancePortabilityandAccountabilityActHIPAAwaspassedbytheU.S.governmentin1996inordertoestablishprivacyandsecurityprotec.onsforhealthinforma.on

• Informa.onstoredonourcomputersisencrypted.Mostpopularemailservices(ex.Hotmail®,Gmail®,Yahoo®)donotu.lizeencryptedemail

• Whenwesendyouanemail,oryousendusanemail,theinforma=onthatissentisnot

encrypted.This meansathirdpartymaybeabletoaccesstheinforma=onandreaditsinceitis

transmi\edovertheInternet.Inaddi=on,oncetheemailisreceivedbyyou,someonemaybeabletoaccessyouremail

accountandreadit.

• Emailisaverypopularandconvenientwaytocommunicateforalotofpeople,sointheirlatestmodifica.ontotheHIPAAact,thefederalgovernmentprovidedguidanceonemailandHIPAATheinforma.onisavailableinapdf(page5634)ontheU.S.DepartmentofHealthandHumanServiceswebsite-h^p://www.gpo.gov/fdsys/pkg/FR-2013-01-25/pdf/2013-01073.pdf

• Theguidelinesstatethatifapa.enthasbeenmadeawareoftherisksofunencryptedemail,andthatsamepa.entprovidesconsenttoreceivehealthinforma.onviaemail,thenahealthen.tymaysendthatpa.entpersonalmedicalinforma.onviaunencryptedemail

OPTION1–ALLOWUNENCRYPTEDEMAIL IunderstandtherisksofunencryptedemailanddoherebygivepermissiontoEclipseTherapyLLCtosendmepersonalhealthinforma.onviaunencryptedemail

OPTION2–DONOTALLOWUNENCRYPTEDEMAIL Idonotwishtoreceivepersonalhealthinforma.onviaemail

Pleaseprintemailaddress_______________________________



12

AssignmentofBenefits

IauthorizepaymentofbehaviorhealthbenefitstoEclipseTherapyLLCand/orcliniciansatEclipseTherapyLLCfortheseservicesandallfutureclaims.Youshouldalsounderstandyouwillberesponsibleforallnon-coveredservicesbecauseoflackofauthoriza.onorforanyotherreasonfordenial.

Iauthorizethereleaseofnecessarymedicalinforma.ontoprocessinsuranceclaims.

PermissiontoPhotograph

IgivepermissionandconsentforEclipseTherapy,LLCtotakephotosofmychildand/ormyselfduringthe.memychildisenrolledinservices.Iunderstandthesephotographsmaybeusedineduca.onaltrainingpresenta.ons.

Child'sname:_____________________Dateofbirth:_________________

___________________________________________________________

PermissiontoVideotapeorAudiotape

IgivepermissionandconsentforEclipseTherapy,LLCtovideotapeand/oraudiotapemychildand/ormyselfduringthe.memychildisenrolledinservices.Iunderstandthesetapeswillnotbeusedoutsidethecompanyandwillbekeptconfiden.al.Iunderstandthatthetapeswillbeusedforthepurposesofdevelopingmoreeffec.veeduca.onalandtherapeu.cplansformychildandalsoforthepurposeofeduca.onandtrainingforEclipseTherapy,LLCandthefamily.




13


Inaddi.ontotheabove,IalsogivepermissionforEclipseTherapy,LLCtouserecordedvideosegmentstopresenttoparentsandprofessionalsforconferencesand/orothertrainingpurposes.




14

CHILD&ADOLESCENTINTAKEQUESTIONNAIRE

Confiden=al

Thefollowingques.onnaireistobecompletedbythechild'sparentorlegalguardian.Thisformhasbeendesignedtoprovideessen.alinforma.onbeforeyourini.alappointmentinordertomakethemostproduc.veandefficientuseofour.me.Pleasefeelfreetoaddanyaddi.onalinforma.on,whichyouthink,maybehelpfulinunderstandingyourchild.EclipseTherapy,LLCwillholdinforma.onprovidedbyyouisstrictlyconfiden.alandwillonlybereleasedinaccordancewithHIPPAguidelinesandasmandatedbylaw.Pleaseusethebacksofthepagesforaddi.onalinforma.on.

PLEASEPRINT

Name of Person Completing this form

Legal Name of Child/Adolescent

Nickname or name child routinely goes by

Child's Date of Birth

Current Age

Age of Diagnosis

Home Address (Primary Residence)

Home Address (Secondary)

Home Telephone Number (primary)

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Pleasedescribetheproblemsyourchildisnowhaving,andwhattypeofservicesyouareseekingfromusfortheseproblems.Pleaseusethebackofthispageforaddi.onalspace.

Home Telephone Number (Secondary)

Work Telephone Number (Mother)

Work Telephone Number (Father)

Cell (Mother)

cell (Father)

School Name

Teacher

Grade

School telephone number

Grade

Who referred you to our practice

16

INDICATEPARENT/GUARDIANSLIVINGINTHEHOME

MaritalStatus

Ifdivorced,

Mother’sInforma.on:

Father’sInforma.on

Married Remarried Devorced Separated Widowed Single Cohabitants

Who has physical custody

Is if full or joint

Who has legal custody

Is is full or joint

Mother’s Name

Date of birth

Age

SSN

Occupation

Employer

Email

Education Completed

Health Condition

Mother’s Name

Date of birth

Age

17

Doeseitherparent'sjobrequirehim/hertobeawayfromhomelonghoursorextendedperiods?

Religious/SpiritualAffilia.on

Siblings

Pleaselistaddi.onalSiblings

SSN

Occupation

Employer

Email

Education Completed

Health Condition

Name Age Relationship School Grade

18

PSYCHOLOGICALHISTORY

Isthereahistoryinyourimmediateorinthemother'sorfather'sextendedfamily,orthefollowingandifsowho?

Hasthechildyouareseekingservicesforbeenevaluatedinthepast?

IfYes,pleaselistthefollowinginforma.ononthepreviousevalua.on(s)(Ifmoreevalua.onsneedtobelistedpleaseusethespaceonthebackofthispage.Ifacopyisavailablepleasea^achforyourchild’scliniciantoreview)

YES NO

Autism Spectrum Disorders

Learning Problems/Disabilities

ADHD ADD Attention Problems

Depression

Bipolar

Behavior Problems in School

Anxiety Disorders

Psychosis/Schizophrenia

Substance Abuse or Dependence

Other Mental Health Concerns

Yes No

Date Evaluation Doctor Diagnosis

19

Ifyes,whatweretheirgeneralfindingsandrecommenda.ons?

Pleaseprovideuswithanyotherinforma.ononthepsychologicalhistorythatyoufeelwouldbehelpfultousinunderstandingyourchild:

Pleaseincludecopiesoftheevalua.ons.

PRE-NATALANDDELIVERYHISTORY

Werethereanycomplica.onswiththePregnancy?

IfYes,pleaseprovidetreatmentdetails:

WasbirthatFullTerm?

IfNo,pleaseprovidedetail:

Yes No

Yes No

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TypeofDelivery:Spontaneous/InducedVaginal/C-Sec.on

Complica.ons?

IfYes,Pleaseprovidedetails:

ConcernsatBirth?

IfYes,pleaseprovidedetail-includinganytreatmentsgiven(Addi.onalspaceonbackifneeded):

Isthereanyaddi.onalpre-natalorbirthinforma.onthatmightbeofassistancetous?

Yes No

Birth Weight

Apgar

Yes No

21

DEVELOPMENTALHISTORY

1.Pleaseindicatetheageatwhichyourchilddidthefollowing:

2.Pleaseindicateifyourchildisexperiencinganyofthefollowing:

Rolled over consistently

Sat up unsupported

Stood

Crawled

Walked

Dressed Self

1st words

Said Intelligible work to stranger

Used phrases

Talked in Sentances

Potty Trained During the Day

Dry through the night (6+ months)

Problems with eating

Isolated socially from peers

Problems making friends

Problems keeping friends

Problems getting to sleep

Problems controlling temper

Nightmares

Bed Wetting / Soiling

Problems with authority

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Listanyopera.on,seriousillnesses,injuries(especiallyhead),hospitaliza.ons,allergies,earinfec.ons,orotherspecialcondi.onsyourchildhashad.

Listanymedica.onsyourchildiscurrentlytakingorhastakenforextendedperiods(givedosagelevelifpossible):

Child’scurrent:

Withwhichhanddoesthechildwrite

Anxiety

Unmotivated

School concentration difficulties

Grades dropping or consistently low

Sadness or Depression

Substance Abuse

Hospitalization Cause Date Allergies

Medication Dose Start Date

Height

Weight

Left

Right

I don’t know

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7.Doesthechildhaveanyvisionproblems?Pleaselistdateoflastvisiontestandwhoperformed(pediatrician,optometrist,School)

8.Doesthechildhaveanyhearingproblems?

Pleaselistdateoflasthearingtestandwhoperformed(pediatrician,optometrist,School)

9.Physicianinforma.on

Name

Practice Name

Address

Phone Number

Fax

24

EDUCATIONHISTORY

Listinchronologicalorderallschoolsyouchildhasa^ended:

SpecialEd?

Name(s)ofcurrentteacher(s)

Doesyourchild'steacherhaveconcernsabouthim/her(list)

Whatisyourchild'sfavoritesubject/class?

Whatisyourchild'sleastpreferredsubject/class?

Name

District

Years

Grade

25

Hasyourchildeverrepeatedagrade?Y/NIfyes,whatgrade(s)?:

IfyourchildhasbeeninSpecialEduca.on,didtheyhavea:

IfyourchildhasbeeninSpecialEduca.on,howweretheyserved?

504 Plan

Occupational Therapy Evaluation

Physical Therapy Evaluation

Adaptive Technology Evaluation

I.E.P.

Psychological Evaluation

Special Evaluation

Behavior Intervention Plan

Consultation

Resource Classroom

Team Taught Classes

Self-Contained Classroom

Psycho educational Center

26

Child'sextracurricularac.vi.es,includingsports,clubs,hobbies,lessons,etc.

10.Listanyspecialabili.es,skills,strengthsyourchildhas:

ACADEMIC

Doyoufeelyourchild'sacademicskilllevelisappropriate?

Wouldyoulikeustoaddressacademicskillsdevelopment?

Collaborative Education

Pull-Out

Special Program

Football Baseball

Cheerleading Basketball

Karate Piano

Scouts Soccer

Dance (type) Music (type)

Gymnastics (type)

Yes No

Yes No

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Coun=ng

Canyourchildiden.fynumbers?

Othernumberskills:

All Some None

Single Digit Numbers1-10

Double Digit 10-99

Higher

Yes NoCan count to 10Can count to 20Can count 20+Can your child count out a number of objects up to 5Can your child count out a number of objects up to 10Can your child count out a number of objects up to 10+Can he/she complete simple addition math problems? (Single digit) Can he/she complete simple subtraction problems?

28

Reading

Canyourchildiden.fyle^ers?

ReadingComments:

All Some None

Lowecase

Uppercase

Identify letter sounds

Yes NoIdentify blends (e.g. sh, st, cr)Can sound out words with blendsCan read simple words (2-4 letter simple words - cat, dog, sat)Can read longer words and sight words (there, just, jump) Can sound out unknown wordsCan read simple sentencesCan comprehend what he/she is reading (can understand and answer questions about what's been read)

29

SELFCARE

Doesyourchilddresshim/herself?

Doyouhavesafetyconcernsregardingyourchild'sac.vi.esathome?

Explain:

Self-CareComments:

Independent With Assistance Does Not

Does your child bathe him/herself?Grooming (brushing teeth, combing hair)Does your child clean up after him/herself




Yes No

30

ATTENDING/ENGAGEMENT

Engagement

A^endingComments:

Always Sometimes Never

DoesyourchildmakeeyecontactwithothersAnswerorlookwhennameiscalledDoesyourchildfollowgesturesfromothersDoesyourchildengageinactivitiesorgamesthatarenottheirideaCanyourchildappropriatelyplaybyhim/herself?

WithDistraction

Canyourchildanswerquestionswhenthereisbackgroundnoise,otherpeople,distraction?Doesyourchildappeartounderstanddirectionsandquestions?Doesyourchildappeartohaveagoodmemory?

31

BEHAVIOR

Tantrums/Aggression/Self-Injury:Doesyourchildhavetantrumsthatyoufeelneedtobe

address?

Describebehavior:

Whattriggersatantrum?

Frequency

Doesyourchildreactaggressivelyat.mes?

Yes NoWhen told "no" (you can't have that/can't do that)When he/she is not getting attention or wants attention To avoid non preferred activitiesTo escape a non preferred task/activity For no obvious reason

1 or more per month

One or more per week

One or more per day

One or more per hour

Yes No

32

Describeaggressivebehaviors:

Whattriggersaggressivebehavior?

Frequency

DoesyourchildengageinSelf-injuriousbehavior(hurthimselforherself)?Describeself-injuriousbehavior:

WhatTriggersSelfInjuriousBehavior

Yes NoWhen told "no" (you can't have that/can't do that)When he/she is not getting attention or wants attention To avoid non preferred activitiesTo escape a non preferred task/activity For no obvious reason

1 or more per month


One or more per day


Yes NoWhen told "no" (you can't have that/can't do that)

33

Frequency

PhysicalStereotypicBehavior:

Frequency

When he/she is not getting attention or wants attention To avoid non preferred activitiesTo escape a non preferred task/activity For no obvious reason

1 or more per month


One or more per day


Yes NoDoes your child flap his hands/arms Does your child seem to look at his fingers in a stereotypic way Does your child seem to look out of the side of his/her eyes Does your child walk on his/her toes Does your child rock (sit and rock back and forth)

1 or more per month

34

VerbalStereotypicBehavior:

Frequency

Persevera.on:


One or more per day


Yes NoEcholalia (repeats what is said/heard Immediate) Delayed Echolalia (will repeat what's been said/heard later)Self-talkHumming to self - inappropriate Screech or yell inappropriately for no apparent reason Scrip videos or cartoon

1 or more per month


One or more per day


35

Frequency

Transi.on/Rou.nes:

Frequency

Yes NoDoes he/she get stuck on a topicGet obsessive about specific peopleGet obsession about specific objects

1 or more per month


One or more per day


Yes NoHas trouble with sudden changeHas trouble with changes that they are warned aboutDoes your child fear any specific objects, animals, places or people?

1 or more per month


36

Fears:Ifyes,explain

SENSORYISSUES

Doesyouchildhavesensi.vityto(ifyesexplain):BehaviorComments:

Frequency

SensoryComments:

One or more per day


Sound Light Touch Texture Smells

1 or more per month


One or more per day


37

IMITATIONOFMOVEMENTSANDSPEECH

Imita.onComments

SPEECH

Doyouhaveconcernsregardingdyspraxiaorapraxia?

Ifyesexplain

Doesyourchildrepeatwhathe/shehasheardotherpeopleorTVcharacterssay?

Ifyesexplain

Doesyourchilduseacommunica.onsystemsuchasPECS,sign,augmenta.vedevice,etc?

Yes NoCan imitate movements when they are demonstrated (clap hands, touch head when someone else is doing the same and he/she is asked to "do this" or "clap hands") Can imitate motions that go along with a song Can imitate a word or words when told to "say_____"

Yes No

Yes No

38

Ifyesexplain

_

SpeechComments:

LANGUAGE

Doesyourchildappeartounderstandlanguage?

Wordsinisola.on-caniden.fyobjectswhenasked

Caniden.fyac.ons("whereistheboywhoisrunning"whenshownapicturesofkidsplaying)

Caniden.fydescribingwords(redvs.blue,bigvs.li^le)

Canunderstandsimplesentences("drinkyourmilk.")

Canunderstandmorecomplexsentences("gogetyourredshoes,"or"givemetheonethatisnotwet")

Canhe/shefollowdirec.ons?

Yes No


Yes No

Yes No


Yes No

Yes No

39

withdelay("ateryoufinishea.ng,gogetyourshoes")

Doesyourchildusethefollowingwhenspeaking:

LanguageComments:

Yes No

One Step Two Step Three Step

Always Sometimes NeverUse when speaking

Nouns (people, places and things)Verbs (action words)Adjectives (describing words)Prepositions (in, out, on etc.)Pronouns (I, you, she, he)Simple sentences (3-4 word)Sentence Descriptors (it’s a black dog

Use Language To request needs/wantsTo greet othersTo respond to greetingsAnswer simple questions

40

SOCIAL/PLAY

Doesyourchildseekoutsocialinterac.onwith:___adults____siblings____peers

SocialComments:

FINEMOTORSKILLS

Always Sometimes NeverDoes your child play

Independently

Next to others

With other children

With toys

Games Skills

Plays gamesTakes turns independentlyNeeds assistance

Verbal SkillsTalks to peers during playTalks to self during playdoes not talk

What hand do the write with Left Right Don’t know

Always Sometimes NeverFine Motor

Hold a pencil

Trace

41

Doyouhaveconcernsregardingyourchild'sgrossmotorskills?

Explain:

PARENT/FAMILYPRIORITIES&PREFERENCES

Topthreeareas/goalsyouwouldliketoseechangeforyourchildinnext6months:

INTERVENTIONSTYLES

Inordertoaccomplishgoalssetforyourchild,werelyonavarietyofresearch-basedmethodsandstyles.Weassessyourchild'sneedsandemploymethodsthatwillmaximizeyourchild'sskillacquisi.on.Belowyouwillseealistofvariousstyles.Wewouldliketounderstandyourfamiliaritywitheachinterven.ontypeasthoseyouthinkmaythinkwouldworkbestforyourchild'spersonality/needsatthis.me.PleasesnotethatthisisNOTanexhaus.velistofmethods.

Copy Letters

Copy Words

Yes No

1

2

3

STYLE/METHOD Familiar with style/method?

May use with my child?

Errorless learning (teaching without allowing errors)

Y N DK Y N DK

Fluency based instruction/precision teaching

Y N DK Y N DK

42

AreyoucurrentlyseeinganyABAprovidersorotherBehavioralHealthProviders(psychiatrist,psychologist,counselor,ect)Y/NIfsopleaselistandfilloutaconsenttoreleaseinforma.onforcon.nuityofcare:

Functional Communication Training

Y N DK Y N DK

Incidental Teaching (following child's lead) around the house

Y N DK Y N DK

Incidental Teaching (following child's lead) in structured play

Y N DK Y N DK

One-to-one intervention (discrete trial) at desk or table

Y N DK Y N DK

PECS (Picture Exchange Communication System)

Y N DK Y N DK

Peer play dates Y N DK Y N DK

Positive Behavior Support working through behaviors and replacing behaviors with appropriate skills

Y N DK Y N DK

Self-management plans (for behavior other skills)

Y N DK Y N DK

Sign Language Y N DK Y N DK

Social Groups Y N DK Y N DK

Use of food as "reinforcer" (with the intent to fade as quickly as possible - we only use as a place to "start" if needed)

Y N DK Y N DK

43

SUPPORTINGBEHAVIORS

Some.meswhenteachingourclientsappropriatereplacementbehaviors,studentsmaybecomeupsetorcry.Whenthishappens,weareveryadeptatworkingthroughtheseinstanceswithfavorableoutcomes.Wewanttounderstandhowyoufeelaboutthiswhenithappens.(Pleasenotethatallbehaviorsupportplansarediscussedwithparentsandstrategiesforrespondingareexplainedandapproved.Providerscandebriefparentsaterany"difficult"sessionsaswell.)

_______Iamcomfortablewithledngmychildcryandledngprovidershandlethesitua=on_______IamNOTcomfortablewithledngmychildcryandledngprovidershandlethe

situa=on_______Iamunsureatthis=me

Comments:

DISCIPLINEINFORMATION:

Parentsmayuseawiderangeofdisciplinestrategieswiththeirchildren.Listedbelowareseveralexamples.Pleaseratehowlikelyyouaretouseeachofthestrategieslisted:

Discipline Strategy How Likely Rating

Let situation go 1 2 3 4 5

Take away a privilege (ex., no TV)

1 2 3 4 5

Take away something material

1 2 3 4 5

Assign an additional chore 1 2 3 4 5

Physical Punishment 1 2 3 4 5

Reason with child 1 2 3 4 5

44

GobackandratetheTHREEMOSTeffec.vestrategies.Thatis,placea1bythemosteffec.ve,a2bythenextmosteffec.ve,anda3bythethirdmosteffec.ve.PleasecircletheLEASTeffec.ve.

Pleaseratewhatpercentageofdisciplineishandledbyeachofthefollowing:Father:_____%Mother:____%Other:_____%(PleaseSpecify:)_________________________________

Pleaselistthefivethingsyouwouldlikeforyourchildtodomoreofandlessofinorderofprioritytoyou.Forexample,insteadofsaying,"Iwantmychildtobemoreresponsible,"translatethatintoactualbehaviorssuchasdohouseholdchores,careforbrothersandsister,etc.

Send to room 1 2 3 4 5

Ground child 1 2 3 4 5

Send to time out 1 2 3 4 5

Yell at child 1 2 3 4 5

Ignore child 1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Like child to do more often Like child to do less often

45

ParentGuidelinesandPolicies

Yourcoopera.ononthefollowingisgreatlyappreciatedtoassistusinworkingwithyourchildatanop.mallevel:

1. Aparentorresponsibleadultmustbeinthehomewhentherapyisbeingprovided.2. Thetherapistmustwait15minutesifchildisnotthereatthetherapy.meandthenis

allowedtoleave.Youmaybechargedforthesessionandthisisnotbillabletoinsurance.3. Thetelephonenumbersofalltherapistswillbegiventoparentssotheycancontact

theirtherapistdirectly.Pleasedonotcallthetherapistsbefore8amandnotater9pm.4. Parentsshouldcontactatherapist24hourspriortotheappointmentiftheparent

knowstheyaregoingtocancelasession.Ifmorethan25%ofsessionsarecancelledina3-monthperiod,yourchildmaylosetheirtherapyslot.

5. Sickness.Pleaseno.fythetherapist,asmuchinadvanceaspossible,atleastthenight,beforethescheduledsessionifyouknowthatyourchildwillnotbeabletopar.cipateintherapythenextday.Sicknessincludes,butnotlimitedtothefollowing:

a. Temperatureabove100b. Mumpsc. RingWormd. CommunicableDiseasee. ChickenPoxf. StrepThroatg. Foot/MouthDiseaseh. Measlesi. Licej. Vomitk. Diarrheal. Rashm. PinkEye

6. Parentsareaskedtousethesameguidelinesusedinaschool-ifachildistoosicktoa^endschool,heorsheistoosicktopar.cipateinhis/hertherapysession.Therapywillresumeassoonasthechild'sdoctorclearshim/herofbeingcontagiousortheremedyiscompleted.Ifatherapistarrivesatthehomeandthechildissick,thetherapistwillnotbeabletoworkwithyourchild.

7. Thetherapistwillcall/textthefamilyiftheyaregoingtobearrivingmorethen5minuteslate.

8. Ifparentscancelasession,thesehoursarenotmadeupunlessthetherapistagreestodoso.

9. Ifatherapistcancelsasession,thesehoursmaybemadeupassoonaspossibledependingonthetherapistavailability.

10. Therapyschedulesshouldbeconsistenttoreduceschedulingerrors.Clearlytherewill

46

beoccasionslikeadoctorsvisitwhereasessionmaybemoved,butthatshouldbeararityratherthanthenorm.

11. Atherapistcannotchangeappointment.meswithoutagreementwiththefamily.12. Inthecaseofsnoworinclementweather:

a. Pleaselistentotheradioforannouncementsofschoolclosingforthedistrictinwhichyoureside.Ifthedistrictschoolsarecloseditisanindica.onthatdrivinginthatareapresentsdangerEclipseTherapytherapistshouldnotreporttoworkthatday.

b. Sinceschoolsinthedistrictareclosedoninclementweatherdays,the.memissedonthosedayscanbemadeupatthediscre.onofthetherapistandthefamily.

13. Incaseofanaccidentorunusualincident,thetherapistshouldcompleteaformandinformthefamilyandtheirsupervisorwithin1businessday.

14. Parentsandtherapistshouldberespec{ulandcourteoustoeachother.Opencommunica.onbetweenparentsandtherapistisessen.altotheestablishmentofasuccessfulprogramforthechild.Allcommunica.onmustbedoneinacourteousandrespec{ulmanner.Ifthereareanyproblemsorconcerns,pleasecontacttheBCBAorBCaBASupervisorimmediately.

15. Parentsareencouragedtosharewiththerapistsanyinforma.onthatmaybehelpfulinge|ngtoknowtheirchildandwillenablethemtoworksuccessfullywiththechild.

16. Periodicvideotapingofsessionsmaybehelpfulinassessingtheprogressofthechild.Priortoavideotapingsession,permissionmustbeobtainedbyallpar.esinvolvedandcanbeterminatedatany.me.Addi.onally,parentsmayrequestacopyofthetapedsessiononamediumprovidedbythem.

17. EclipseTherapyfeelsthatitisimportanttoincludeallfamilymembersintherapy.a. Siblingsarewelcometopar.cipateintherapyaslongastheyareahelpful

addi.ontothesession.b. Parentsarewelcomeandshouldpar.cipateintherapysessions.c. Cheatsheetsspecifictoyourchildwillbecreated.Therapistandsupervisorswill

goovertheseindetailandprovidemodelingandcoachingforyouonthesestrategies.

Informa=onRelatedtoSchedulingandSessions

Contac=ngus

Giventheirmanyprofessionalcommitments,ourtechniciansareotennotimmediatelyavailablebytelephoneoremail.Ifyouneedtoleaveamessage,wewillmakeeveryefforttoreturnyourcalloremailpromptly(within24hourswiththeexcep.onofholidaysandweekends.).Ifyouaredifficulttoreach,pleaseleavesome.meswhenyouwillbeavailable.Becauseofthenatureoftheservicesweprovide,wedonotprovideon-callcoverage24hoursperday,7daysaweek.Inemergencyorcrisissitua.ons,pleasecontactyourphysician,orcall911and/orgotothenearesthospitalemergencyroom.

ServicesOffered

47

Wewillprovideservicesspecificallydesignedtohelpyourchild,orifwecannothelpwewillprovideyouwithreferralstootherprofessionalswhomaybeabletoserveyourchildandhis/herneeds.Ourbehavioralservicesconsistprimarilyofassessments,inhome/schoolbehavioralservices,parenttraining,andongoingcollabora.onwithotherprofessionals.

YourchildwillhaveanABAtechnicianorteamofABAtechnicianfromEclipseTherapyassignedtohis/hercase.Eachtechnicianhasatleasthighschooldiplomaandhascompleteda40-hourtraininginAppliedBehaviorAnalysisandvaryingexperienceprovidingservicestochildrenwithAu.smandotherbehavioral/developmentaldifficul.es.ABoardCer.fiedBehaviorAnalystorBoardCer.fiedassistantBehaviorAnalystoverseesallcases.

ABAsessionsareusuallyscheduledintwo-threehourblocks.Theresearchisclearthatlongersessionsresultingreaterreten.onandthismakesschedulingmoreconvenientforallpar.es.Ifthisisnotconvenientforyourfamily,pleasebringthisupduringattheintakemee.ng.

Exceptincasesofemergency,24hoursno.ceisrequiredforallcancelledappointments.Paymentfortheappointmentisrequiredforallmissedappointmentsnotcancelledaccordingtothispolicy.Insurancecarriersarenotresponsibleformiss-appointmentfees.

Werequestthatfamiliesgiveusatleasttwoweeksno.ceonsignificantchangesintheirplansforin-homeABAsessionsschedulinginordertofacilitateconsistencyinservicedelivery.

ThestandardofcareoutlinedintheABAInterna.onal'sRevisedGuidelinesforConsumersofAppliedBehaviorAnalysisServicestoIndividualswithAu.smincludessupervisionoftherapistsonanongoingbasis,programconsulta.on,programreview,andprogramrevisionasservicesperformedbyaBCBA.Theseservicesarenecessaryforaprogramtomeetminimumprofessionalstandardsandarenotop.onal.

Appointments

Exceptforrareemergencies,wewillseeyourchildatthe.mescheduled.Weunderstandthatcircumstances(suchasanillnessorfamilyemergency)mayarisewhichnecessitatestheoccasionalcancella.onofappointments.Inthesecases,inordertoavoidanymisunderstanding,weaskthatyouspeaktoyourtherapistpersonallyandgiveasmuchno.ceaspossibletocancelorreschedule.Thiswillallowustobestplanforthesitua.on.

Youmaybechargedthestandardhourlyrate(seefeeschedule)forappointmentsmissedorcancelledwithlessthan24hoursadvanceno.ce.Pleasenotethatinsurancecompanieswillnotreimburseyouformissedappointmentsandyouremainresponsibleforthesecharges.

Cancella=onandSessionA\endancePolicy

48

Cancella.onsmustbedonenolessthan24hourspriortothescheduledsession.Iftheclientcancelsmorethantwo.meswithout24-hourno.ce,EclipseTherapycanreduceordiscon.nueservices.

Clientswillpar.cipatein80%ofscheduledsessionspermonth.Otherwise,theclientwillhaveonemonthtoreach80%par.cipa.oncriteria,orEclipseTherapycanreduc.onordiscon.nua.onofservices.Excep.onsmaybemadeifthereareextrememedicalcondi.onsthatrequirehospitaliza.on,andadoctor’snote.

Clientswillprovideaminimumof2weeksno.ceforvaca.onslas.ngmorethan3days.Iftheclientdoesnotprovide2weeksno.cemorethanonce,Eclipsecanreduceordiscon.nueservices.

Confiden=ality,Records,andReleaseofInforma=on

Servicesarebestprovidedinanatmosphereoftrust.Becausetrustissoimportant,allservicesareconfiden.alexcepttotheextentthatyouprovideuswithwri^enauthoriza.ontoreleasespecifiedinforma.ontospecificindividuals,orunderothercondi.onsandasmandatedbyColoradoandFederallawandourprofessionalcodesofconduct/ethics.Theseexcep.onsarediscussedbelow.

Toprotecttheclientorothersfromharm

Ifwehavereasontosuspectthataminor,elderly,ordisabledpersonisbeingabused,wearerequiredtoreportthis(andanyaddi.onalinforma.onuponrequest)totheappropriatestateagency.Ifwebelievethataclientisthreateningseriousharmtohim/herselforothers,wearerequiredtotakeprotec.veac.onswhichcouldincludeno.fyingthepolice,andintendedvic.m,aminor'sparents,orotherswhocouldprovideprotec.on,orseekingappropriatehospitaliza.on.

ProfessionalConsulta=ons

BehaviorAnalystsrou.nelyconsultaboutcaseswithotherprofessionals.Insodoing,wemakeeveryefforttoavoidrevealingtheiden.tyofourclients,andanyconsul.ngprofessionalsarealsorequiredtorefrainfromdisclosinganyinforma.onwerevealtothem.Wewilltellclientsabouttheseconsulta.ons.Ifyouwantustotalkwithorreleasespecificinforma.ontootherprofessionalswithwhomyouareworking,youwillfirstneedtosignanAuthoriza.onthatspecifieswhatinforma.oncanbereleasedandwithwhomitcanbeshared.

HealthInsurance

Ifwefileyourinsuranceclaims,youareresponsibleforco-payment.Youarealsoresponsibleforalloranypor.onofthebillthatyourinsurancedoesnotcoverordenies.

49

ProfessionalRecords

Youshouldbeawarethat,pursuanttoHIPAA,wekeepclients'ProtectedHealthInforma.oninonesetofprofessionalrecords.TheClinicalRecordincludesinforma.onaboutreasonsforseekingourprofessionalservices;theimpactofanycurrentorongoingproblemsorconcerns;assessment,consulta.ve,ortherapeu.cgoals;progresstowardsthosegoals,amedical,developmental,educa.onal,andsocialhistory;treatmenthistory;anytreatmentrecordsthatwereceivefromotherproviders;reportsofanyprofessionalconsulta.ons;billingrecords;releases;andanyreportsthathavebeensenttoanyone,includingstatementsforyourinsurancecarrier.

Pa=entsRights

HIPAAprovidesyouwithseveralneworexpandedrightswithregardtoyourClinicalRecordanddisclosuresofprotectedhealthinforma.on.Theserightsincludereques.ngthatweamendyourrecord;reques.ngrestric.onsonwhatinforma.onfromyourClinicalRecordisdisclosedtoothers;reques.nganaccoun.ngofmostdisclosuresofprotectedhealthinforma.onthatyouhaveneitherconsentedtonorauthorized;determiningtheloca.ontowhichprotectedinforma.ondisclosuresaresent;havinganycomplaintsyoumakeaboutourpoliciesandproceduresrecordedinyourrecords;andtherighttoapapercopyofthisAgreement,thea^achedNo.ceform,andourprivacypoliciesandprocedures.Wearehappytodiscussanyoftheserightswithyou.

Pleasesignsta.ngyoureceivedtheparentguidelinesandpolicies


50

FUNCTIONAL ASSESSMENT SCREENING TOOL (FAST)

Name: ____________________________________ ___ Age: ___________ ___ Date: _________ _

BehaviorProblem: _______________________________________________________________ _

Informant: ___ -'--__________________ _ Interviewer: ______________________ _

To the Interviewer. The Functional Analysis Screening Tool (FAST) is designed to identify a number of factors that may influence the occurrence of problem behaviors. It should be used only as an initial screening toll and as part of a comprehensive functional assessment or analysis of problem behavior. The FAST should be administered to several individuals who interact with the person frequently. Results should then be used as the basis for conducting direct observations in several different contexts to verify likely behavioral functions, clarify ambiguous functions, and identify other relevant factors that may not have been included in this instrument.

To the Informant: After completing the section on "Informant-Person Relationship," read each of the numbered items carefully. If a statement accurately describes the person's behavior problem, circle "Yes." If not, circle "No." If the behavior problem consists of either self-injurious behavior or "repetitive stereotyped behaviors," begin with Part I. However, if the problem consists of aggression or some other form of socially disruptive behavior, such as property destruction or tantrums, complete only Part II.

Informant-Person Relationship Indicate your relationship to the person: __ Parent ___ Teacher/lnstructor ___ Residential Staff ___ Other

How long have you known the person? __ Years ___ Months

Do you interact with the person on a daily basis? __ Yes ___ No

If "Yes," how many hours per day? If "No," how many hours per week? ___ _

In what situations do you typically observe the person? (Mark all that apply) __ Self-care routines

__ Leisure activities

___ Academic skills training ___ Work/vocational training

___ Meals

___ Evenings __ When (s)he has nothing to do __ Other: _____________ _

Part I. Social Influences on Behavior 1. The behavior usually occurs in your presence or in the presence of others Yes No

2. The behavior usually occurs soon after you or others interact with him/her in some way, such as delivering an instruction or reprimand, walking away from (ignoring) the him/her, taking away a "preferred" item, Yes No requiring him/her to change activities, talking to someone else in his/her presence, etc.

3. The behavior often is accompanied by other "emotional" responses, such as yelling or crying Yes No Complete Part/l if you answered "Yes" to item 1, 2, or 3. Skip Part/l if you answered "No" to all three items in Part I.

Part II. Social Reinforcement 4. The behavior often occurs when he/she has not received much attention Yes No

5. When the behavior occurs, you or others usually respond by interacting with the him/her in some way (e.g., comforting statements, verbal correction or reprimand, response blocking, redirection) Yes No

6. (S)he often engages in other annoying behaviors that produce attention Yes No

7. (S)he frequently approaches you or others and/or initiates social interaction Yes No

8. The behavior rarely occurs when you give him/her lots of attention Yes No

9. The behavior often occurs when you take a particular item away from him/her or when you terminate a preferred leisure activity (If "Yes," identify: ) Yes No

10. The behavior often occurs when you inform the person that (s)he cannot have a certain item or cannot engage in a particular activity. (If "Yes," identify: ) Yes No

11. When the behavior occurs, you often respond by giving him/her a specific item, such as a favorite toy, food, or some other item. (If "Yes," identify: ) Yes No

12. (S)he often engages in other annoying behaviors that produce access to preferred items or activities. Yes No

13. The behavior rarely occurs during training activities or when you place other types of demands on him/her. (If "Yes," identify the activities: ____ self-care __ academic __ work __ other) Yes No

Adapted from the Florida Center on Self-Injury

Functional Assessment Screening Tool Page 2

14. The pehavior often occurs during training activities of when asked to complete tasks.

15. (S}he often is noncompliant during training activities or when asked to complete tasks.

16. The behavior often occurs when the immediate environment is very noisy or crowed.

17. When the behavior occurs, you often respond by giving him/her brief "break from an ongoing task.

18. The. behavior rarely occurs when you place few demands on him/her or when you leave him/her alone.

Part III. Nonsocial (Automatic)Reinforcement 19. The behavior occurs frequently when (s}he is alone or unoccupied

20. The behavior occurs at relatively high rates regardless of what is going on in his/her immediate surrounding environment

21.. (S}he seems to have few known reinforcers or rarely engages in appropriate object manipulation or "play' behavior.

22. (S}he is generally unresponsive to social stimulation.

23. (S }he often engages in repetitive, stereotyped behaviors such as body rocking, hand or finger waving, object twirling, mouthing, etc.

24. When (s}he engages in the behavior, you and others usually respond by doing nothing (Le., you never or rarely attend to the behavior.)

25. The behavior seems to occur in cycles. During a "high" cycle, the behavior occurs frequently and is extremely diffieult to interrupt. During a cycle the behavior rarely occurs.

26. The behavior seems to occur more often when the person is ill.

27. (S}hehas a history of recurrent illness (e.g., ear or sinus infections, allergies, dermatitis).

Scoring Summary Circle the items answered "Yes." If you completed only Part 1/, also circle items 1, 2, and 3

Like/r.. Maintaining Variable

1 2 3 4 5 6 7 8 Social Reinforcement (attention)

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes -,>

Yes

Yes

1 2 3 9 10 11 1? .13 Social Reinforcement (access to specific activities/items) 1 2 3 14 15 16 17 18 Social Reinforcement (escape)

19 20 21 22 23 24 Automatic Reinforcement (sensory stimulation)

19 20 24 25 26 27 Automatic Reinforcement (pain attenuation)

Comments/Notes:

Adapted from theFIorida Center on Self-Injury

Nt;)

·NcIl No

No

No

No

No

No

No

No

No

No

No

No

Welcome to Eclipse Therapy...Welcome to Eclipse Therapy Dear Family, Star.ng therapy for your child...

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