NEW PATIENT INTAKE FORM

PERSONAL INFORMATION

INSURANCE INFORMATION (please fill out ALL areas)

Please initial the following statement

EMERGENCY MEDICAL RELEASE

In the event medical attention is required for your child while in the premises of Stepping Stone Kids Therapy, we need your authorization to implement treatment. Please read and sign the statement below.


As legal guardian of

I give my permission for Stepping Stone Kids Therapy to contact emergency personnel in the event of a medical emergency.

MEDICATION/ALLERGIES/CONDITIONS

I

state that the above is true and complete to the best of my knowledge, I authorize Stepping Stone Kids Therapy to provide food items fitting within the parameters above to my child for behavior reinforcers. If applicable, I authorize Stepping Stone Kids Therapy to administer the EpiPen that I have provided for my child in the event of an anaphylactic emergency. I understand that by signing this form I am releasing Stepping Stone Kids Therapy of any liability herein.

PHOTO PERMISSION

Please initial the following OPTIONAL statement

TECHNOLOGY PERMISSION

Please initial the following OPTIONAL statements

AUTHORIZATION AND CONSENT FOR EVALUATION, TREATMENT, AND OPERATIONS

Please initial the following statements

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES (HIPAA)

I acknowledged that I have viewed, read, and understand the HIPAA Policy (attached at the end of this packet) and have been informed of my rights as a patient’s parent/guardian.

List the names of the programs and people that have worked or are working with your child outside of Stepping Stone Kids Therapy

I hereby authorize any prior or present treating physician, therapist, school, hospital, or other health institution, to release all of medical information by any means of communication to Stepping Stone Kids Therapy LLC.

History Form

**If your child has an IEP through his/her school, please bring us a copy for our records. ** **If your child has any additional testing, please bring us a copy for our records. **

Please answer the questions to the best of your ability and in as much detail as possible. Please add any information that you feel is important but is not covered on this form.

General History

Developmental History

Please indicate at what age each major milestone was reached

If your child was adopted, please answer the following questions

Educational History

Agreements

Stepping Stone Kids Therapy offers ABA therapy services for patients referred to our practice. We are a licensed provider who develops individualized treatment plans to identify the services that will best suit your child’s therapy needs. Following the initial assessment visit. We are pleased to serve your ABA needs and encourage your feedback to alert us to anything we can do to provide your child with the highest quality of care. We require certain information from each patient to begin providing care. The attached forms need to be completed for us to begin serving your child as our patient. Please do your best to complete all the information. If certain information does not apply to your child, please indicate that by noting “N/A” (“Not Applicable”) so that we know that you did not overlook anything. Each healthcare insurance payor has different guidelines for allowing coverage of ABA services. It is helpful if you let us know your healthcare payor when starting service so that we may find out if prior authorizations are needed. If your child is a Medicaid beneficiary, please ask your primary care provider to send us a referral for your initial assessment to fulfill Medicaid requirements. If your healthcare insurance payor does not cover ABA services, you are welcome to make self-pay arrangements for the usual and customary pricing of our services. PRIVATE INSURANCE CO-PAYMENTS, DEDUCTIBLES, AND NON-COVERED SERVICE Private insurance companies may have limits on the amount of ABA/OT/SP covered. Once you have exceeded the financial limit of your benefits and you do not have additional healthcare coverage, you are responsible for the payment of your child’s services. Additionally, private healthcare insurance payers have deductibles and copayments for ABA/OT/SP services that are the responsibility of the patient. While this practice will not discontinue your child’s services for financial hardships, it is expected that patients pay at the time of service and/or set up payment arrangements. *Please see attached patient payment policy and credit card authorization form PRIVATE PAY Payment is due at the time of service. Once a year your child will receive a reassessment to update current plans and review progress. This requires an additional fee; our clinic manager will schedule date and time for the reassessment and discuss payment and fee associated. COLLECTION OF PAST DUE ACCOUNTS We communicate with our patients’ parents/guardians to resolve past due accounts in all cases. If we cannot reach a patient’s parent/guardian by phone following the return of undeliverable mail, or if a patient payment agreement cannot be made or paid as agreed, we are forced to use the services of a professional collection agency. Once an account is placed with a collection agency, we cannot take the account back. Please let us know when or if your patient contact information changes so that we can always reach you, if needed, to discuss past due accounts. QUALITY ASSURANCE & COMPLAINT RESOLUTION Should you or your child’s caregiver experience a situation that requires the attention and resolution of a Supervisor and/or Manager, please contact our practice either in writing or by phone at (239) 351-3715. A member of our management team will interact with you to reach a resolution of any identified situation where our quality of service has been compromised. We use such situations to alert us to improvements we can make to better serve all our patients. PATIENT STATEMENT OF AGREEMENT My signature below signifies that I have read and understand this patient agreement for Stepping Stone Kids Therapy to provide ABA services. I agree to the terms in this patient agreement and intend to comply with them to the best of my ability. I understand that if I fail to follow the terms of this agreement, I could be discharged from service.

FINANCIAL POLICY

We are committed to providing you with the best possible care. If you have medical insurance, we are willing to help you receive your maximum allowable benefits. To achieve these goals, we need your assistance and your understanding of our financial policy. Payment, co-payment, deductibles, and co-insurance for services are due each visit for charges incurred up through your last visit. We accept cash, checks, VISA, MasterCard, and Discover Card. Please understand that you are financially responsible for all charges, whether they are paid by insurance. Please read carefully: Your insurance is a contract between you, your employer, and your insurance company. We are not a party to that contract. As a courtesy to our patients, we will bill your insurance carrier; however, we cannot guarantee payment in a timely manner. If for any reason any portion of a bill is not paid by your insurance within 60 days from the date of service, you agree to make arrangements for prompt payment. Should your insurance coverage change, our office should be notified within 30 days of the effective date and the card or stickers should be available for copying. If you fail to provide us this information, your account and all future balances will be your responsibility. We will no longer bill insurance and you will be responsible for submitting claims to your insurance. Payment will also be due at the time of service in full. Any returned checks will be subject to an NSF fee of $25.00 which will be due at the next visit.

Please initial the following statements

I hereby understand the above financial policy and agree to abide by it.

CANCELLATION POLICY

Our clinic strives to provide the best therapy services possible. To ensure optimal use of valuable therapy time, please discuss schedule changes at the end of your appointment with your therapist and the front desk administrator/clinic manager. We understand occasional changes are necessary due to illness, vacations, etc. Please call our office within 24 hours of a scheduled appointment if you need to cancel or reschedule that appointment. This allows for clients to reschedule into additional openings therapists may have. For Monday morning appointments, our office appreciates being notified no later than Friday noontime. This will allow other patients in need of care to be accommodated as we have many patients. It is both unfair to the other patients and therapists to not allow for others to schedule in the open time slots.

Please initial the following statements

We are happy to work out scheduling problems with you. Please let us know if you are experiencing a problem with your current schedule. If therapy needs to be canceled for a couple of weeks, (such as for an extended trip), we will hold your therapy spot for up to two weeks. We will then place you on the information list and will fit you back in the schedule as soon as we can.

CLINIC ETIQUETTE

Once again, we welcome you to Stepping Stone Kids Therapy. We are honored that you have chosen our clinic to meet the needs of your child and your family. We hope that you are comfortable here and always feel welcome. Please know that you can approach us with any comments or concerns regarding our space and how it is used. To make a comfortable and safe place for all our families and our staff, we ask that families follow our clinic etiquette plan. Please read and become familiar with the following expectations. Before entering treatment areas without a therapist, please check in at the front desk/clinic manager to allow for patient confidentiality and compliance with HIPAA policies. Closely monitor your children’s behavior in the waiting room to ensure that they are playing safely and appropriately with other children. Please do not allow children to climb on, jump from, or disassemble the waiting room furniture or toys. Please clean up after your children in the waiting room. Help them replace any books or toys they may have used and throw away any trash that may have accumulated. Accompany all younger children and those needing assistance or supervision to the restroom; this includes using the restroom for hand washing. If you have children in diapers or pull-ups, please bring a diaper bag to therapy and be prepared to change your child if necessary. Do not allow your children to enter the treatment area unaccompanied. For safety reasons, please do not allow your children to play with the doors in the waiting room. We discourage bringing toys from home to treatment sessions unless your therapist requests them or gives permission to bring them. Your therapist will choose toys from our clinic with a specific therapeutic purpose. If you are observing your child’s treatment session, remain in the same room as your child and their therapist. To protect the confidentiality of all children in our clinic, we ask that if you need to leave the treatment room for any reason, you return to the waiting room and wait for the session to end. If your child and their therapist leave the room, either follow them or wait for them in the waiting room. Please keep cell phone and tablet use to a minimum in treatment areas and place phones on vibrate or silent. Cell phone and tablet use is acceptable in the waiting room and other common areas, but please keep phone conversations brief and use headphones if watching videos or listening to music. Please take extended phone conversations outside the waiting room. Please be mindful of the content discussed in your conversations (phone or in-person) or viewed on your electronic devices. Please only discuss topics or select websites, videos, music, etc. which are appropriate to discuss/view in the presence of children. Please do not ask therapists about other clients or families at the clinic. To comply with HIPAA, we cannot answer these questions. Be respectful of the ‘end of session’ time. Please arrive 10-15 minutes prior to the end of the therapy session. In most cases, there is another family waiting to begin therapy. If you need additional time to discuss a concern, ask questions, or problem-solve treatment activities, please join your child’s session or arrange for an alternative time to discuss those topics with your child’s therapist. As your team, you can expect us to: Begin and end your appointments in a timely manner. Inform you of the goals targeted and the progress made during each session. Provide strategies and ways for you to address goals at home to increase carryover. Provide parent training Assist you in any way we can, from brainstorming ideas to help make your families’ lives easier at home to talking with school therapists, etc. Keep anything you share with us confidential. Provide the best therapy we possibly can. If you have any questions about the above information, please don’t hesitate to ask us. We are here to help you! I have read and understand the above Clinic Etiquette and agree to abide by it.

STEPPING STONE KIDS THERAPY SCOPE OF PRACTICE

Characteristics of Persons Served: Children ages 2 to adolescence (less than 16 years of age for new clients and up to 18 years of age for continuing clients) may be served. Medical Acuity & Medical Stability: Children must be healthy and cleared for treatment by their physician. Children may not receive services if they have illnesses such as: fever of 100.5 or greater; pink eye; vomiting and/or diarrhea; or other highly contagious viruses and/or diseases. Admission Criteria: Children who experience delays, or are at significant risk for delays, in any area of development which negatively affects his/her functional performance and ability to participate in home, community and school activities. Children from 2 through 16 years of age will be considered for evaluation. Children 16 years and older may be seen on a case by case basis if he/she has lost a skill due to an accident or illness. Financial responsibility is established in accordance with the Financial Policy. An evaluation is completed which identifies the need for intervention. Additional factors considered before admission include areas of expertise of therapy staff and availability of appropriate treatment materials and equipment. If a client would benefit from treatment but is not approved for services due to the factors previously identified, he/she may be referred to other agencies that can provide needed services. Discharge Criteria: It is our policy to discharge clients who meet any of the following criteria: are 18 years of age; no longer demonstrate need for intervention; do not appear to benefit from continued services; are not meeting financial responsibilities; do not meet the required attendance; are removed at the request of the caregiver; or are removed at the discretion of the agency (including for safety reasons). No Longer Demonstrates Need: If a child has demonstrated sufficient progress in therapy and testing reveals the child’s skills are at age- appropriate levels (i.e., no further intervention is indicated), the therapist will review the child’s progress with the parent/caregiver and plan a discharge date. Does Not Appear to Benefit: Progress in therapy is reviewed on a continuous basis. If a client does not meet therapy goals and/or does not demonstrate progress on re-evaluation after six months in therapy, the treating therapist will discuss the lack of progress and the treatment plan with their clinical supervisor and the child’s caregiver. They may revise the treatment plan to better fit the child’s needs at any time. If a client does not meet therapy goals and/or does not demonstrate progress on a re-evaluation during the second six-month treatment period, the treating therapist will discuss the treatment plan with their clinical supervisor and the child’s caregiver. An interdisciplinary team review shall be initiated. This discussion will include the possibility of revising the treatment plan, increasing or decreasing the frequency of sessions, and discharge if no progress continues to be noted. At the end of 18 months of treatment, if no progress has been noted and the above steps were taken, the client may be discharged. Financial Responsibility: If a family is not meeting financial responsibilities to the agency as outlined in the Financial Policy, the client may be discharged from therapy. Poor Attendance: Poor attendees may be discharged per the Attendance Policy. Parent/caregiver Request: Discharge will be completed upon caregiver request. Agency Discretion: The agency reserves the right to discharge any client at any time for any reason. Changing Therapists A child may, at one time or another, experience a change in his or her therapist. This may happen for any one of the following reasons: Therapist relocation Therapist illness or family emergency Scheduling issues in which the family requests a different day of the week or time of day for ongoing therapy sessions. We will accommodate changes as they arise; however, this will occasionally result in the child switching therapists. Lack of progress or ‘connection’ with the child’s assigned therapist. Our number one goal is for the child to receive a maximum benefit from therapy. Occasionally, a child has a personality conflict with the assigned therapist or just does not develop a good working relationship with the assigned therapist. In cases like this, it is in the best interest of the child to re-assign them to a different therapist. Additionally, the child or therapist may reach a point where the child still needs therapy but is failing to make acceptable progress. The change to a new therapist may assist the child to begin making progress once again. Change in the specific therapist’s schedule. We make every effort to maintain continuity of care with as few changes as possible. When changes do arise, we will assist families in making the transition as smooth as possible. Evaluation and Intervention: Therapeutic evaluation and intervention are provided by state licensed and appropriately credentialed BCBA. Registered Behavioral Therapists (RBT) provide services under the supervision of our BCBA’s. In a collaborative process with the child and his/her parent/Guardian, outcomes for therapeutic intervention are created and reassessed every 6 months to determine frequency and duration of service.

NON-EVIDENCED BASED TREATMENTS There may be times when you wish to explore other treatments for your child while he/she receives ABA services. Many services and treatments are evidenced based with ABA and we will make every effort to ensure that all professionals are working towards the same goals. However, some therapies and/or treatments may not be evidenced based treatment programs. In these cases, we will not be able to accommodate these treatments into your child’s program. If you choose to use non-evidenced based treatments, you must let your Supervisor know when services begin and when there are changes in treatments. Please speak with your Supervisor for more details.

DIAPER CHANGING/POTTY TRAINING

I authorize Stepping Stone Kids Therapy staff to change my child

diaper and assist with potty training if I am unavailable. I agree to supply an extra change of clothes, wipes, diapers and any other supplies needed. I release Stepping Stone Kids Therapy staff from all responsibility concerning this matter.

HIPAA Form

This release of information will remain in effect until terminated by patient or guardian in writing

CONSENT FOR TREATMENT OF MINORS

This is to certify that the information on the intake forms are accurate to the best of my knowledge. I have permission to Stepping Stone Kids Therapy to provide treatment for my child. I verify that all legal guardians are aware of and giving consent for this treatment as well.

Guidelines for Parent Training

Your child’s success in therapy is very important to the team at Stepping Stone Kids Therapy. You are an important member of the team. The following are recommendations to maximize your child’s success in therapy. Attend and be on time for all scheduled parent training appointments. Parents are responsible to attend 2 trainings per month. Parent training will be for one hour per training. Arrive 10 minutes prior to the training to meet your child’s therapist to review the session as well as participate in training. If you must cancel, call 24 hours in advance when possible. Communicate any concerns or observations regarding your child . If there are any questions or concerns about therapy,or interventions , please ask for your therapist or call BCBA for further clarification . Follow recommendations and training tips that a therapist provides to you on a regular basis. Be mindful when discussing your child’s behaviors, major life stressors, or other dynamics with your child's therapist . We recommend discussing significant behaviors or concerns in private. The above recommendations have been reviewed with me and I agree to follow these guidelines as outlined above.

WALKING PERMISSION SLIP

On occasion, we may take a walk around the surrounding area to work on skills in the natural environment or for reinforcement. These walking trips are not always planned in advance. By signing this permission slip, you are giving Stepping Stone Kids Therapy staff members permission to take your child on a walk. Both staff and child will be accompanied by one or more staff members and signed in and out of the building upon leaving and returning from walks If you choose not to have your child participate in this activity, please indicate your wish below. We will ensure your child does not leave the building until pick-up. If at any point you wish to no longer allow your child on walks or would like to allow them on walks, please let us know. In the event of an emergency, it might be necessary to remove your child from the building for their safety in which you will be notified immediately.

FOOD PERMISSION SLIP

Food may be used as reinforcement or to provide exposure to new foods during a therapy session. Some foods used may include: Dum Dum Lollipops, pretzels, Goldfish, Skittles, and/or M&Ms. Your child’s BCBA will notify you in the case that your child’s program includes exposure to new foods. All items will be store bought, store prepared, and store packaged; at no time will any item be homemade. Please list any food allergies below, so that there is never an incident in which your child is knowingly given a food they are allergic to. If you would prefer to use a specific food item or brand, you are welcome to supply them and they will be offered only to your child. In the event of an emergency and your child has an allergic reaction to something they have eaten, you will be notified immediately.

Occupational/Speech CANCELLATION POLICY

We understand occasional changes are necessary due to illness, vacations, etc. Please call our office within 24 hours of a scheduled appointment if you need to cancel or reschedule that appointment. If you are no call/no show or less than 24 hours for two appointments, the director will schedule a meeting with the parent/guardian. Three no-call/no-show or cancellations less than 24 hours, the Director of Operations will speak with the parent/guardian to discuss a resolution. Four no-call/no-show or cancellations less than 24 hours will result in discharge.

E-Signature Consent

This form is affirm that all parties consent to the use of Electronic Signatures