AUTHORIZATION TO RELEASE INFORMATION/PAYMENT OF INSURANCE BENEFITS: I hereby authorize Creative Consultants, Inc. to furnish my insurance carrier any information acquired in the course of my evaluation or treatment necessary to complete my insurance forms. Also, I hereby assign to Creative Consultants, Inc. all payments for services rendered. In the event that my insurance company does not pay for services rendered, I understand that I am fully responsible for all payments due.
By entering your name you are signing that the above information is correct:
Due to the medical needs of our clients, we require that parents/caregivers cancel therapy sessions for the following reasons:
Your child may begin receiving services after an illness within the below listed time periods:
IN CONSIDERATION OF the matters described above and of the mutual benefits and obligations set forth in this Agreement, the receipt and sufficiency of which consideration is hereby acknowledged, the parties to this Agreement agree as follows:
By checking 'Yes' in the CONFIRM box below and entering your initials you are signing that you agree to the terms and conditions as stated in the above contract:
THIS NOTICE DESCRIBES HOW CONFIDENTIAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION, PLEASE REVIEW IT CAREFULLY.
As a client or applicant for services of Creative Consultants, Inc. we may use or disclose personal related information about you in the following ways: Your protected health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment and written consent is given by you directly.
This notice is effective as of Jan 1,2010. This notice, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created.
Click below to CONFIRM Authorization and sign below by typing entering your Initials: My Initials acknowledges that I have received a copy of this notice.
I hereby authorize Creative Consultants Inc. to submit claims for services covered under my insurance plan, on my behalf. By checking and initializing the box below, I give Creative Consultants the authorization to bill said insurance directly and disclose any documents necessary to the insurance company for continued services.
I certify that by checking the CONFIRM box below and entering my initials below on this release and consent form gives permission to Creative Consultants, Inc., the full right to use my child's photograph(s) and/or videotaped image(s) and sound byte(s) in its staff training, educational seminars, and promotional efforts. I willingly agreed to have my child's photograph(s),videotaped image(s), sound byte(s) taken knowing that it could be used in various publications and/or broadcasts in the State of North Carolina and/or throughout the United States.
Creative Consultants INC. requires that a caregiver over the age of 18 be present at all times while a Tutor or a Consultant is engaged in session. If for some reason you or another adult caregiver is not available during the session you may submit a formal request asking that you be granted permission to leave your child alone with the Tutor or Consultant during session. Creative Consultants will review each request and make a formal decision based on the family's specific needs.
If you are approved to leave your child alone with the Tutor or the Consultant there must be an adult over the age of 18 present no less than 5-minutes prior to the end of the session. Failure to comply with this regulation may result in approval being terminated and reinstating of the requirement that an adult be present at all times.
We ask that parents give 24 hours notice for cancellations, in the form of a phone call/ voice mail to the Tutor or Consultant providing services. Cancellations (or “no shows”) without 24 hour notice are subject to a cancellation fee of $50.
Insurance is a contract between you and your insurance company. We will bill your primary insurance company as a courtesy to you. In order to properly bill your insurance company we require that you disclose all insurance information including primary and secondary insurance, as well as, any change of insurance information. Failure to provide complete insurance information may result in patient responsibility for the entire bill. It is the insurance company that makes the final determination of your eligibility and benefits. If your insurance company is not contracted with us, you agree to pay any portion of the charges not covered by insurance, including but not limited to those charges above the usual and customary allowance. If we are out of network for your insurance company and your insurance pays you directly, you are responsible for payment and agree to forward the payment to us immediately.
*If an insurance company remits payment for services directly to you please submit check immediately to Creative Consultants.
Payment is due upon receipt of invoice. Our office will be happy to work with you in order to pay any balance due to our practice. Please contact our billing department for qualifying options.
Outstanding Balance Policy
If no resolution can be made, the account will be sent to the collection agency, or attorney, and possible discharge from the practice. In the event an account is turned over for collections, the person financially responsible for the account will be responsible for all collections costs including attorney fees and court costs.
*We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. (Any change in our privacy notice will apply for all of your health information in our files.)
If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaint to: Denise Freeman DeCandia at 919.371.2848.
As a patient, family member, or responsible guardian, you have the right to:
Discuss verbally or in writing, the grievance with the clinical supervisor within seven (7) days of the alleged grievance. The clinical supervisor will investigate within seven (7) days after the receipt of such grievance and make every effort to resolve the grievance to the patient’s satisfaction.
If the grievance cannot be resolved to the client’s satisfaction, the client or his designee is to notify the director in writing. The grievance must state the problem or action alleged and the date the supervisor was notified.
The director will investigate the grievance in an attempt to resolve the difference and notify the client in writing of the resolution of the grievance. The clinical supervisor and the director can be reached at 919-371-2848 and 111 Mackenan Dr. Cary, NC 27511.
If the client feels his/her grievance has not been resolved after working with Carolina Center for ABA and Autism Treatment, he/she is encouraged to notify the North Carolina Psychology
Board at (828) 262-2258 or on the web at http://www.ncpsychologyboard.org/filingacomplaint.htm and/or the BACB at http://bacb.com
This document describes the nature of the agreement for professional services, the agreed upon limits of those services, and rights and protections afforded under the Behavior Analyst Certification Board’s Guidelines for Responsible Conduct of Behavior Analysts. I will receive a copy of this document to retain for my records. All fees for services and payment arrangements will be reviewed separately.
I agree to have my child/dependent participate in applied behavior analysis (ABA) assessment and/or treatment services provided by Creative Consultants Group, Inc. DBA Carolina Center for Applied Behavior Analysis and Autism Treatment. I understand that the specific activities, goals, and desired outcomes of these ABA services will be fully discussed with me and that I will have the opportunity to ask for clarification prior to signing this document. I also understand that I have the right to ask follow-up questions throughout the course of service delivery to ensure my full participation in services. I understand that my child/dependent is the primary client of the behavior analyst and that services will be designed primarily for his/her benefit. Any other individuals or agencies (e.g., family, school professionals) that may be affected by the ABA services are considered secondary clients.
If the ABA services focus on increasing my child’s skills, I understand that the first several sessions will consist of assessment activities designed to (a) evaluate his/her current skills (e.g., curricular assessments) and (b) determine which instructional strategies and interventions are likely to prove most effective (e.g., preference assessments, assessment of prompting strategies). The time allocated to these assessments will result in improved intervention. If the services are designed to improve ongoing problem behaviors, I understand that the beginning of those services will include functional assessment and/or functional analysis activities (e.g., interviews, checklists, direct observations) that are designed to provide information critical to the development of effective treatment procedures. I may be asked to assist in gathering some of this information by recording problem behavior as it occurs.
The subsequent services will be focused on development of and implementation of instructional procedures and/or a behavior intervention plan. Prior to implementation, I will receive a printed copy of the results of any assessment and of any proposed instructional procedures or behavior intervention plans for my approval. The contents of those documents will be explained to me fully and any questions I have will be answered to my satisfaction. Subsequent implementation will involve training in the basics of ABA that are important for the intervention, details about the specific components of the ABA intervention, and direct practice in the components for the family, educators, and/or other service providers. Full participation in these implementation and training activities is critical for a successful outcome. Ongoing collection of data will allow evaluation of the effectiveness of the intervention and will assist in developing any revisions that need to be made to ensure a good outcome. In addition, at regular progress reviews we may also discuss whether continuation of services would be beneficial, and any barriers to continuation.
Behavior analysts are ethically obligated to provide treatments that have been scientifically supported as most effective. I am aware that other interventions that I am pursuing may affect my child’s response to ABA treatment. Thus it is important to make the behavior analyst aware of those interventions and to partner with the behavior analyst to evaluate any associated therapeutic or detrimental effects of those interventions.
I understand that the procedures and outcomes of all assessment and treatment services are strictly confidential and will be released only to agencies or individuals specifically designated by me in writing. In addition, the fact that my child/dependent receives any services is protected and private information. I am aware that CCABA may release information without my prior consent if so ordered by a court of law. I am also aware that providers are legally required to report suspected occurrences of child abuse or neglect or if I or my child present clear and present danger to ourselves or to others.
I understand that the provider agency employs individuals at the bachelor’s level who are supervised by the BCBA’s and LP/LPA’s . I understand that my child’s assessment and treatment services may be observed by supervisors or other employees as part of ongoing training and quality assurance activities. Events occurring in those sessions will be discussed in closed supervision meetings. I am aware that a record of the treatment will be maintained and this record is available to me in written form upon request.
I understand that it may be necessary to audio- or videotape assessment and/or treatment sessions for supervision purposes. In the event that audio- or videotaping is necessary, I will be informed and asked to give written consent prior to taping (enclosed in the new client packet). If the assessment or treatment involves formal research that goes beyond normal evaluation or clinical procedures, I reserve the right to consent or refuse to participate.
I reserve the right to withdraw at any time from these services and I understand that such a withdrawal will not affect my child’s right to services. In the event of withdrawal, I may request a list of other credentialed providers in the region. In addition, I reserve the right to refuse, at any time, the treatment that is being offered.
I am aware that the relationship between provider and client is a professional one that precludes ongoing social relationships, giving of gifts, personal social media connections, or participation in personal events such as parties, graduations, etc.
I may request a copy of the BCBA’s current professional credentials upon request. In addition, any concerns that I have about BCBA’s performance can be directed to the Clinical Director at 919.371.2848.
We ask that parents give 24 hours notice for cancellations, in the form of a phone call and voicemail to the Tutor or Consultant providing services. Cancellations (or “no shows”) without 24 hours notice are subject to a cancellation fee of $50. The Tutor or Consultant will bill for this $50 fee and the parent will receive a bill along with their monthly co-pay to cover this.
Late Drop-Off (for sessions at clinic locations)
If a parent is more than 15 minutes late for the session, they are responsible for paying the rate of $50/hour, or $12.50 per 15 minutes they are late. Tutors and Consultants will bill for this time, and parents will receive a bill for this fee along with their monthly co-pay bill to cover this. Tutors and Consultants will contact the family after 15 minutes has passed and inform them that they are leaving, (unless the parent is near-by and both parties agree to have session). If the Tutor or Consultant attempts to reach the family unsuccessfully, the Tutor or Consultant should attempt to leave a voicemail stating that the session is cancelled. This policy is also in effect for sessions in the home or school when the child is not present at the stated session start time.
Late Pick-Up (for sessions at the clinic)
Our Tutors and Consultants often have sessions back-to-back, so it’s important that parents are on time for pick-up, so the next session can start on time. If a parent is more than 15 minutes late in picking their child up from session, they are responsible for paying the rate of $50/hour, or $12.50 for each 15-minute period they are late. This will be billed to the parent, along with their monthly co-pay bill. If a parent is more than 15-minutes late, more than twice, we reserve the right to require a parent to be on site for all sessions (if in the clinic) or ask those sessions take place in the home.
Please understand that these policies are in place in order for our staff to best implement the programs prescribed for all of our clients. Some of our staff work on a contract basis, and often when they have cancellations or no-shows, they have opportunities to provide needed hours for their other clients. We understand that emergency situations arise, on both ends (staff and parents), and these situations will be handled on a case-by-case basis. Our Tutors and Consultants are also expected to give 24 hours notice for cancellations and are expected to call if they will be late due to traffic or other unforeseen circumstances. If parents feel that cancellations or late sessions are becoming “excessive”, please contact your Consultant, or directly contact the office to discuss. We appreciate your understanding of the need for these policies in continuing to provide services to your children!
CCABA staff follows the Behavior Analyst Certification Board Guidelines for Responsible Conduct.
These guidelines can be found and read here http://www.bacb.com/index.php?page=57
In accordance with these guidelines, the following policies are in place:
The BACB Ethical Guidelines require that Dual Relationships between provider (Consultant/Tutor) and consumer (client/family) be avoided. The relationship between the provider and the consumer should be a professional one, with focus on the client and his or her Plan of Care. To prevent dual relationships from forming, the following policies have been developed.
In regards to Social Media (i.e. Facebook, Twitter, Instagram, text messaging, etc):
It is CCABA policy that staff is not connected to client/consumers through social media websites including, but not limited to Facebook, Twitter, Instagram, etc. If text messaging is the preferred form of communication for the parents to discuss scheduling, cancellations, etc, the content of text messages need to be client-focused. In addition, all email communication should be client-focused. An appropriate avenue for families to be connected to CCABA staff and to find out about CCABA news and events is the CCABA Facebook page.
In regards to gifts (birthday, holidays, goodbyes…):
In order to prevent potential dual relationships from forming, CCABA has a gift policy in place that prevents CCABA staff from accepting gifts of any type from a client/consumer. While we very much appreciate this token, this can make the relationship between provider and consumer cloudy, and difficult to prevent from turning into a dual relationship. An alternative to purchasing or creating a gift for your child’s Tutor or Consultant at holidays, consider purchasing or creating materials that will motivate your child to learn and can be used during sessions. Along similar lines, we also cannot accept meals during sessions, even if sessions take place during schedules meal times. Staff may bring their meals with them if needed, but cannot accept meals from client/consumer during or outside of sessions.
When a CCABA provider is present during sessions, the focus needs to be on the client and implementation of the plan of care. Communication between provider and parent/sibling, need to be client-focused, such as reviewing progress and discussing new goals or strategies to meet goals. Similarly, when provider and consumer/client communicate outside of sessions (phone, email…), communication should remain focused on the client.
CCABA realizes that many of our clients are receiving services from various providers with training in other disciplines (Speech, OT, PT, Teachers, Music Therapist, MDs…). While CCABA respects the input from these other disciplines and providers, and recognizes the important part each provider plays on each client’s Team, the service we are required to and trained to provide is ABA. ABA includes a collection of evidenced based strategies rooted in the principles of behavior. We, as providers of ABA, have a duty to implement these, and only these, strategies. If you, as a consumer, want to implement a different method than CCABA is trained to implement or is not consistent with ABA principles, your Consultant can help you to assess the effectiveness of the method, but it is against CCABA policy for Tutors or Consultants to implement these methods. Your CCABA Consultant can also set up a meeting with other providers to discuss the methods and strategies we CAN implement and why we suggest those specific strategies in the client’s plan of care.
Policy on Suspected Child Abuse and Neglect - Mandated Reporting:
This policy is to inform our clients and their families about The Carolina Center for ABA and Autism Treatment’s Staff and Contractor status as mandated reporters of child abuse and neglect. As mandated reporters, our providers have a legal obligation to report suspected child abuse or neglect. In our roles as ABA providers, we are not trained to say whether an observed or reported incident is abuse or neglect. However, there are certain situations that we are required, by law, to report. Often, these situations are not clear, and since we don’t have the training to say whether an incident is abuse or neglect, we must make a report to allow those trained in making these determinations come in and offer support that we can’t provide. Ultimately, the goal is to ensure that our clients and families have the support that they need on all levels.
Please be aware that if a report is made, we are not making an accusation that abuse or neglect is occurring. We are, as objectively as possible, retelling a situation as it was reported or observed and allowing those professionally trained in these matters do their jobs to ensure the safety of the child or other family member(s).
If a difficult situation like this were to occur, please understand that first and foremost, our priority is continued support in your child’s and family’s life to ensure safety and well being. Sometimes this involves requesting the help of other providers offering services outside of our scope. If circumstances allow, we will always try to be as open and honest about our concerns. Please also understand that failure on our part to report certain concerning situations may result in civil or criminal action against us.
In our experience, the best outcomes in these situations occur when families are open and cooperative in the steps that take place following a report being made., and continue to welcome the support of current providers. We will make every effort to continue to offer our support, or refer to another provider if necessary.
If you have any questions or concerns about this policy or about child abuse and neglect reporting laws, please see http://www2.ncdhhs.gov/dss/cps
If you are in need of support or services to prevent or stop child abuse or neglect, please Call Prevent Child Abuse North Carolina at 1-800-CHILDREN. They can put you in touch with someone who can offer support and help.
PROFESSIONAL RELATIONSHIP, LIMITATIONS AND RISKS
What I Do
Behavior analysis is a unique method of treatment based on the idea that most important human behavior is learned over time and that it is currently maintained by consequences in the environment. My job as a behavior analyst is to work with behavior you would like to change. With your input, I can help you discover what is maintaining a behavior, discover more appropriate replacement behaviors, and then set up a plan to teach those behaviors. I can also develop a plan to help you acquire a new behavior or improve your skill level. Some of the time I will be treating you directly and at other times I may be training significant others as well.
How I Work
As a behavior analyst I do not make judgements about behavior. I try to understand behavior as an adaptive response (a way of coping) and suggest ways of adjusting and modifying behaviors to reduce pain and suffering and increase personal happiness and effectiveness.
You will be consulted at each step in the process. I will ask you about your goals, I will explain my assessment and the results of my assessment in plain English. I will describe my plan for intervention or treatment and ask for your approval of that plan. If at any point you want to terminate our relationship, I will cooperate fully.
Please know that it is impossible to guarantee any specific results regarding your goals. However, together we will work to achieve the best possible results. If I believe that my consultation has become non-productive, I will discuss terminating it and/or providing referral information as needed.
I can only work with clients who fully inform me of any and all of their concerns. I will need your full cooperation as I try to understand the various behaviors that are problematic for you. I will be asking a lot of questions and making a few suggestions and I need your total honesty with me at all times. I will be showing you data as part of my ongoing evaluation of treatment and expect that you will attend to the data and give me your true appraisal of conditions.
One of the most unique aspects of behavior analysis as a form of treatment is that decisions are made based on objective data that are collected on a regular basis. I will need to take baseline data to first determine the nature and extent of the behavior problem that we are dealing with; then I will devise an intervention or treatment and continue to take data to determine if it is effective. I will show you this data and will make changes in treatment based on this data.
Under my code of ethical conduct I am not allowed to work with you in any other capacity except as your behavior therapist or consultant. If I am working in your home with your child it is not appropriate for you to leave the premises at any time or to ask me to take your child to some other location that is not directly related to my services.
Although our relationship involves very personal interactions and discussions, I need you to realize that we have a professional relationship rather than a social one. According to my professional code of ethics, it is not appropriate for me to accept gifts or meals and it is not appropriate for me to be involved with your personal activities such as birthday parties, or family outings.
I will need a list of any prescribed or over-the-counter medications and/or supplements in addition to any medical or mental health conditions; this information is kept confidential. Please note that I am not able to provide any supplements and/or medications directly to your child.
I expect that if you need to cancel or reschedule your appointment that you call as soon as you are aware of the change. If I do not receive 24-hour notification of your cancellation or you fail to show for an appointment or show 15 minutes after scheduled start, then you may be charged for the appointment. Please refer to Carolina Center's current Family Packet for details of our cancellation policies.
CODE OF CONDUCT
I assure that my services will be rendered in a professional and ethical manner consistent with accepted ethical standards. I am required to adhere to the Guidelines for Responsible Conduct of the Behavior Analyst Certification Board®. A copy of these Guidelines are available upon request.
If at any time and for any reason you are dissatisfied with our professional relationship, please let me know. If I am not able to resolve your concerns, you may report these to the following: Behavior Analyst Certification Board, Inc. • 1705 Metropolitan Boulevard, Suite 102 • Tallahassee, Florida 32308 850-386-4444 www.bacb.com
Clients and their therapists have a confidential and privileged relationship. I do not disclose anything that is observed, discussed or related to clients. In addition, I limit the information that is recorded in your file to protect your privacy. I need you to be aware that the confidentiality has limitations as stipulated by law including the following:
If you have an urgent matter please contact the main office directly, or call 911 or the mental health center emergency room .. In addition, you should be aware that any e-mail communications may be made part of your permanent medical record. If you wish to receive services, you must sign this agreement indicating that you understand and accept the policies about confidentiality and its limits.
All complete records will remain on file for a minimum of seven years after the last contact with the client and, if the client in a minor, the records will be maintained until three years after the age of majority. You can request these records at any time. Because these are professional records, though, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. I require a completed and signed written Request and Authorization for Release of Health Information Form before releasing any documents to anyone, including the patient. The form must be completed, dated and signed, and I ask that you specify what components of your medical records you wish to obtain.
Please note that, if at any time, the client's behavior is deemed as harmful to self and/or others by the client, family and/or treatment team (Analyst(s), Psychologist(s), Instructor(s)) that an immediate increase of interaction with the client's Supervising Psychologist will be arranged with the client/family. The number of hours required for this is subject to the clinical recommendations of the supervising psychologist. This time may include time needed to analyze data and/or create written/formal intervention plans.
Appointments, Fees and Emergencies
The current fee for BCBA/BCaBA services is $125 per hour. This includes interviewing relevant persons, observation, planning, writing, preparing reports, and attending meetings. If you are receiving services via a third party (insurance carrier) these actions may or may not be covered within your benefits. You will need to verify this information with our Insurance Coordinator.
Bills will be mailed to you from our Cary, NC office. If you have any questions regarding your statements or financial obligations, please contact our Cary office and speak with the Office Manager (Rosanne Jones) and/or the Executive Director (Denise Freeman-DeCandia).
Carolina Center for ABA and Autism Treatment
111 Mackenan Drive
Office Manager: Rosanne@carolinacenterforaba.com
Executive Director: Denise@carolinacenterforaba.com
This document is for your records. Please initial the form indicating that you have read, understand and have had the opportunity to ask questions regarding the information in this declaration. Please retain a copy for your records.
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