Applied Behavior Analysis

1Client Service Agreement
2Client Contact
3Client History
4Client / Family Rights and Responsibilities

CONSENT TO TREATMENT

I consent to the following treatment as ordered by my physician and outlined in the treatment plan of care. I understand the risks and benefits of the treatment and I understand that I can ask questions to the treating clinician at any time regarding the treatment.
client full name
Is your primary language spoken English?
If English is not your primary language, an interpreter may be provided by your insurance. Would you like an interpreter for your services?
If yes, please provide language needed
No, I would like to opt out of interpreter services

Please check the appropriate therapy service:

ABA Therapy: ABA therapy is an intervention service that focuses on applying evidence-based techniques and strategies to reduce challenging behaviors, teach functionally appropriate behaviors, and develop skills such as communication, socialization, and forms of self-management. Any client receiving ABA therapy receives an individualized treatment plan that focuses on their specific areas of need. DV highly recommends parent involvement, an ABA treatment plan will also include hours for caregiver education/training and designated goals for caregivers to meet during a service period.(Required)
The recommended treatment areas and service level will be outlined in the Assessment Report provided and explained to you by the clinician. Your permission is needed to implement the assessment recommendations and to further develop treatment plan goals and objects.

VIDEO RELEASE FORM

DV Therapy has permission to record my child's therapy sessions. The video recording will be used for training purposes and will be useful for ensuring quality treatment services for your child. It will not be made public and will have internal use only. Once the video is no longer needed, it will be deleted.

PHOTO RELEASE FORM

DV Therapy has my permission to use mine and/or my child’s photograph publicly to promote the office. I understand that the images may be used in websites, print publications, online publications, presentations, and/or social media. I also understand that no royalty fee or other compensation shall become payable to me by reason of such use.

MAKE-UP SESSIONS

Cancellations on the part of the provider (DV Therapy) or Client may occur during a service period. In order to ensure that a client receives all recommended hours for ABA services, scheduling make-up sessions is crucial to accomplishing this goal. In the event of a provider cancellation (i.e., DV therapist cancels), DV will make attempts to provide an alternative therapist to hold the session at the originally designated time. In the event of a client cancellation (e.g., client is sick), DV will offer dates to make-up the therapy session. In this scenario, the therapist available may be an alternative therapist.

Volunteers / Interns

DV Therapy Inc fosters a learning environment for volunteers and interns to receive observation hours, as well as provide treatment to clients with guidance and supervision by DV Therapy's treating therapists.

Shadow Therapist

DV Therapy Inc fosters a learning environment for new behavior technicians. One such way this is accomplished is by having them "shadow" a session to build on their therapy skills. A "shadow" may observe a session or be given opportunities to interact with a client under the guidance of the behavior technician or ABA Supervisor.

CANCELLATION POLICY

A great deal of effort goes into arranging your treatment schedule. It is important to realize that this therapy time is being held exclusively for you. Clients who make the best and most rapid progress are those who diligently follow the recommended treatment schedule. If you must cancel an appointment FOR ANY REASON, the office must receive a 12-HOUR NOTICE by phone/text/email prior to the scheduled session or it will be considered an “in-valid” cancellation.

As a courtesy, the Scheduling department sends out a confirmation text on the first day of the week (typically monday’s unless a holiday occurs) before the session – if the front office does not hear back that the sessions are confirmed, or prior alternative arrangements have been made, the office will assume that the sessions for the week is confirmed. Please make a point of confirming with the office so there is no confusion regarding the scheduled session.

DV’s minimum attendance policy is for clients to receive 80% or higher of scheduled sessions per month. If a client is under this threshold, steps will be taken to address the barriers. Please review the following for information on what is considered a “valid” reason for cancelling a scheduled therapy session. A valid cancellation will not be calculated into the minimum attendance policy.

Valid Cancellation

The following is a list of “Valid” reasons for a client cancellation:

  • The client is experiencing sickness such as fever, green/yellow mucus or discharge from mouth or nose, vomiting, diarrhea, or rash
    • Client must have broken fever for an entire 24-hour duration (without the use of fever-reducing medications) prior to returning to the office for session
  • Client has a scheduled doctor appointment
    • DV encourages caregivers to schedule any type of doctor appointment outside of direct therapy sessions
  • Family emergency such as death in family or other crisis
  • See below for DV’s COVID-19 Protocol

Any other reason for cancelling a session that is not listed above would be considered an “in-valid” cancellation. DV is understanding that emergencies or other life events can occur that at times is out of the hand of the parent/caregiver; however, DV considers the therapy services to be crucial to the client progressing. Please review the following for penalties that will occur when persistent “in-valid” cancellations accrue.

Verbal Warning:

If 10% or more of scheduled sessions are cancelled due to “in-valid” reasons in a calendar month (e.g., 2 out of 20 sessions in a month), the parents/caregivers of a client will be provided with a verbal warning. The verbal warning will be provided in writing and will require a signature from the caregiver/parent to confirm receipt of the verbal warning. DV will make attempts to determine if the schedule for the client needs to be adjusted to ensure cancellations will not occur.

Second Verbal Warning:

If 10% or more of scheduled sessions are cancelled due to an “in-valid” reason for a second month, within a 6-month authorization period, a second verbal warning will be provided to the caregiver/parent. A behavior contract will be made which will detail objective goals for attendance that the caregiver/parent will abide by for a designated time period. The behavior contract will be signed by the caregiver/parent.

Example Behavior Contract:

To the caregivers of (Client’s Name),

DV’s minimum attendance guideline is for client’s to maintain 80% of their scheduled therapy sessions each month. DV understands that there can be numerous reasons to have to cancel a scheduled session, this can include sickness, scheduling conflicts, or family emergencies. At this time, (Client’s Name) has been unable to maintain the minimum attendance guidelines. Which means that a number of “in-valid” cancellations have accrued to exceed the 80% threshold in (Month/Year). Below is the objective scheduling goals:

For the next two months (December 2021 and January 2022), (Client Name) will attend 90% of scheduled sessions. This requires no more than 2 “in-valid” cancellations, per month, per 2 consecutive months.

If (Client Name) is able to adhere to the contract, (Client)’s behavior contract will be removed and if another instance of a minimum attendance policy occurs, the penalty process will begin at the first verbal warning.

If (Client Name) is unable to adhere to the contract, a second behavior contract will be developed to ensure DV’s minimum attendance policy is followed.

Breaking of Behavior Contract:

If the objective goals set in the initial behavior contract are broken, the client may be subject to having a reduced therapy schedule. A second behavior contract will be made and signed by the caregiver/parent. A second behavior contract will have stricter goals (e.g., 95% attendance per month, per 2 consecutive months).

Breaking of Second Behavior Contract:

If the second behavior contract is broken, the client will be discharged from ABA services with DV therapy. This is due to the client being unable to attend consistent scheduled therapy sessions as clinically recommended and approved for by the insurance provider.

I have read and agree to abide by the Cancellation Policy set forth by DV Therapy Inc.

Parent Name(Required)
Client Name(Required)
MM slash DD slash YYYY
Parent Signature(Required)

COVID-19 Protocol:

As of January 12, 2022

DV Therapy Inc continues to uphold a strict COVID-19 protocol by implementing the following guidelines:

Please read and click “Agree” that you understand the measures being taken.

At this time we will not be able to see both vaccinated and unvaccinated individuals in-clinic if any of the following questions are responded with “yes.”

  • If you, or someone in your home has had flu-like symptoms in the last 7 days?
    • Fever or chills
    • Cough
    • Shortness of breath or difficulty breathing
    • Fatigue
    • Muscle or body aches
    • Headache
    • New loss of taste or smell
    • Sore throat
    • Congestion or runny nose
    • Nausea or vomiting
    • Diarrhea
  • If you have travelled domestically/internationally within the last week
    • Due to the increased spread of the Delta Variant, we are requesting that all individuals who have travelled within the last week must take a COVID PCR Test after the 3-5th day of return and have a negative test.
    • If you do not want to provide a COVID PCR Test, we require you to quarantine and switch over to teletherapy for the next 10 days after your last day of travel.
  • If you, or someone who have been in contact with, tested positive for the coronavirus - quarantine for 10 days.
  • If you, or someone you have been in contact with, has had a fever - according to CDC guidelines, anything over 100.4 - in the last 7 days

**If during the time that you resume in person session, your answer becomes YES to the above questions - please contact our staff immediately to place in person services on hold.

  • Safety measures upon entering the facility
    • Temperature checks will be conducted before entering the facility - anyone who has a temperature of 100.4 or above, will not be allowed in the facility.
    • Please use the hand sanitizer dispensers at the door before entering the facility
    • All adults will be required to wear masks while in the facility
    • In accordance with the CDC recommendation of social distancing, we are requesting that only one parent/guardian bring the client to therapy - this will reduce the amount of people in the clinic and waiting area
    • Checking in will be done via contact less sign in on the iPad or with a clean stylus and will be immediately sanitize after use
    • Parents understand that they are being offered teletherapy services and are choosing to come into the offices for services, when available.
    • While in the waiting room, please allow at least 3-6 feet of space between persons
  • For the safety of the client and the therapist the following steps will be taken during session:
    • The therapist will be wearing face masks throughout the session
    • Once session is complete, the therapist will wipe down all surface areas to ensure that it is clean for the following session
    • All high traffic areas - door knobs, light switches, chairs etc - will be cleaned throughout the day

We are continuing to offer teletherapy services - if you would like to continue being seen via telehealth, please reach out to our staff.

    • 1

      Client Service Agreement

    • 2

      Client Contact

    • 3

      Client History

    • 4

      Client / Family Rights and Responsibilities

    1/4

    Client Service Agreement

    CONSENT TO TREATMENT

    I consent to the following treatment as ordered by my physician and outlined in the treatment plan of care. I understand the risks and benefits of the treatment and I understand that I can ask questions to the treating clinician at any time regarding the treatment.



    YesNo


    Yes, please provide language neededNo, I would like to opt out of interpreter services

    Please check the appropriate therapy service:

    ABA Therapy: ABA therapy is an intervention service that focuses on applying evidence-based techniques and strategies to reduce challenging behaviors, teach functionally appropriate behaviors, and develop skills such as communication, socialization, and forms of self-management. Any client receiving ABA therapy receives an individualized treatment plan that focuses on their specific areas of need. DV highly recommends parent involvement, an ABA treatment plan will also include hours for caregiver education/training and designated goals for caregivers to meet during a service period.


    I agree to the service plan that will be/has been created for the client. I understand that my consent is voluntary and that I may refuse these services at any time.I do not want my child to receive these services.

    I have read and agree to abide by the Consent to Treatment set forth by DV Therapy Inc.

    VIDEO RELEASE FORM


    I give consentI do not consent

    PHOTO RELEASE FORM


    I give consentI do not consent

    MAKE-UP SESSIONS


    I will accept an alternative therapist when my therapist is absent.I will accept an alternative therapist when a make up session is required due to a participant cancellation.I agree with the above statements

    Shadow Therapist


    I agree with the above statements

    CANCELLATION POLICY

    A great deal of effort goes into arranging your treatment schedule. It is important to realize that this therapy time is being held exclusively for you. Clients who make the best and most rapid progress are those who diligently follow the recommended treatment schedule. If you must cancel an appointment FOR ANY REASON, the office must receive a 12-HOUR NOTICE by phone/text/email prior to the scheduled session or it will be considered an “in-valid” cancellation.

    As a courtesy, the Scheduling department sends out a confirmation text on the first day of the week (typically monday’s unless a holiday occurs) before the session – if the front office does not hear back that the sessions are confirmed, or prior alternative arrangements have been made, the office will assume that the sessions for the week is confirmed. Please make a point of confirming with the office so there is no confusion regarding the scheduled session.

    DV’s minimum attendance policy is for clients to receive 80% or higher of scheduled sessions per month. If a client is under this threshold, steps will be taken to address the barriers. Please review the following for information on what is considered a “valid” reason for cancelling a scheduled therapy session. A valid cancellation will not be calculated into the minimum attendance policy.

    Valid Cancellation

    The following is a list of “Valid” reasons for a client cancellation:

    • The client is experiencing sickness such as fever, green/yellow mucus or discharge from mouth or nose, vomiting, diarrhea, or rash
      • Client must have broken fever for an entire 24-hour duration (without the use of fever-reducing medications) prior to returning to the office for session
    • Client has a scheduled doctor appointment
      • DV encourages caregivers to schedule any type of doctor appointment outside of direct therapy sessions
    • Family emergency such as death in family or other crisis
    • See below for DV’s COVID-19 Protocol

    Any other reason for cancelling a session that is not listed above would be considered an “in-valid” cancellation. DV is understanding that emergencies or other life events can occur that at times is out of the hand of the parent/caregiver; however, DV considers the therapy services to be crucial to the client progressing. Please review the following for penalties that will occur when persistent “in-valid” cancellations accrue.

    Verbal Warning:

    If 10% or more of scheduled sessions are cancelled due to “in-valid” reasons in a calendar month (e.g., 2 out of 20 sessions in a month), the parents/caregivers of a client will be provided with a verbal warning. The verbal warning will be provided in writing and will require a signature from the caregiver/parent to confirm receipt of the verbal warning. DV will make attempts to determine if the schedule for the client needs to be adjusted to ensure cancellations will not occur.

    Second Verbal Warning:

    If 10% or more of scheduled sessions are cancelled due to an “in-valid” reason for a second month, within a 6-month authorization period, a second verbal warning will be provided to the caregiver/parent. A behavior contract will be made which will detail objective goals for attendance that the caregiver/parent will abide by for a designated time period. The behavior contract will be signed by the caregiver/parent.

    Example Behavior Contract:

    To the caregivers of (Client’s Name),

    DV’s minimum attendance guideline is for client’s to maintain 80% of their scheduled therapy sessions each month. DV understands that there can be numerous reasons to have to cancel a scheduled session, this can include sickness, scheduling conflicts, or family emergencies. At this time, (Client’s Name) has been unable to maintain the minimum attendance guidelines. Which means that a number of “in-valid” cancellations have accrued to exceed the 80% threshold in (Month/Year). Below is the objective scheduling goals:

    For the next two months (December 2021 and January 2022), (Client Name) will attend 90% of scheduled sessions. This requires no more than 2 “in-valid” cancellations, per month, per 2 consecutive months.

    If (Client Name) is able to adhere to the contract, (Client)’s behavior contract will be removed and if another instance of a minimum attendance policy occurs, the penalty process will begin at the first verbal warning.

    If (Client Name) is unable to adhere to the contract, a second behavior contract will be developed to ensure DV’s minimum attendance policy is followed.

    Breaking of Behavior Contract:

    If the objective goals set in the initial behavior contract are broken, the client may be subject to having a reduced therapy schedule. A second behavior contract will be made and signed by the caregiver/parent. A second behavior contract will have stricter goals (e.g., 95% attendance per month, per 2 consecutive months).

    Breaking of Second Behavior Contract:

    If the second behavior contract is broken, the client will be discharged from ABA services with DV therapy. This is due to the client being unable to attend consistent scheduled therapy sessions as clinically recommended and approved for by the insurance provider.

    I have read and agree to abide by the Cancellation Policy set forth by DV Therapy Inc.

    COVID-19 Protocol:

    As of January 12, 2022

    DV Therapy Inc continues to uphold a strict COVID-19 protocol by implementing the following guidelines:

    Please read and click “Agree” that you understand the measures being taken.

    At this time we will not be able to see both vaccinated and unvaccinated individuals in-clinic if any of the following questions are responded with “yes.”

    • If you, or someone in your home has had flu-like symptoms in the last 7 days?
      • Fever or chills
      • Cough
      • Shortness of breath or difficulty breathing
      • Fatigue
      • Muscle or body aches
      • Headache
      • New loss of taste or smell
      • Sore throat
      • Congestion or runny nose
      • Nausea or vomiting
      • Diarrhea
    • If you have travelled domestically/internationally within the last week
      • Due to the increased spread of the Delta Variant, we are requesting that all individuals who have travelled within the last week must take a COVID PCR Test after the 3-5th day of return and have a negative test.
      • If you do not want to provide a COVID PCR Test, we require you to quarantine and switch over to teletherapy for the next 10 days after your last day of travel.
    • If you, or someone who have been in contact with, tested positive for the coronavirus - quarantine for 10 days.
    • If you, or someone you have been in contact with, has had a fever - according to CDC guidelines, anything over 100.4 - in the last 7 days

    **If during the time that you resume in person session, your answer becomes YES to the above questions - please contact our staff immediately to place in person services on hold.

    • Safety measures upon entering the facility
      • Temperature checks will be conducted before entering the facility - anyone who has a temperature of 100.4 or above, will not be allowed in the facility.
      • Please use the hand sanitizer dispensers at the door before entering the facility
      • All adults will be required to wear masks while in the facility
      • In accordance with the CDC recommendation of social distancing, we are requesting that only one parent/guardian bring the client to therapy - this will reduce the amount of people in the clinic and waiting area
      • Checking in will be done via contact less sign in on the iPad or with a clean stylus and will be immediately sanitize after use
      • Parents understand that they are being offered teletherapy services and are choosing to come into the offices for services, when available.
      • While in the waiting room, please allow at least 3-6 feet of space between persons
    • For the safety of the client and the therapist the following steps will be taken during session:
      • The therapist will be wearing face masks throughout the session
      • Once session is complete, the therapist will wipe down all surface areas to ensure that it is clean for the following session
      • All high traffic areas - door knobs, light switches, chairs etc - will be cleaned throughout the day

    We are continuing to offer teletherapy services - if you would like to continue being seen via telehealth, please reach out to our staff.


    TextEmailPhone

    Emergency Contact


    YesNo

    Scheduling Make-ups


    If no, please fill out information below for contact information:

    In order to help us provide the best possible services to you and your child, please complete the following information.

    Prenatal and Birth History


    YESNO

    Motor Milestones and Language

    At what age was your child able to do each of the following:

    Medical History

    Statement of Concern

    Educational Information

    Family Information

    Sensory Profile

    Please describe your child’s responsiveness or sensitivity to the following sensory areas:

    Behavior information


    CLIENT/FAMILY RIGHTS AND RESPONSIBILITIES

    You have the RIGHT to:

    • Effective behavioral treatment
    • Be treated with dignity and respect
    • Receive service that is considerate and respectful of your spiritual needs beliefs and values
    • Receive services in a safe setting, free of all forms of abuse or harassment
    • Receive services without discrimination of age, ability, gender, race spiritual beliefs, ethnic origin, marital status, sexual orientation, or financial status
    • Receive as much information needed about treatments in order to provide informed consent or refuse treatment
    • Access information on the progress of treatments
    • Know the benefits and potential limitation of proposed treatments
    • Refuse to participate in clinical research
    • Access your records within a reasonable timeframe, except specified by law
    • Express concerns or complaints about services without fear that the quality of your services will be affected.

    You have the RESPONSIBILITY to:

    • Refrain from demands for inappropriate or treatments that are not evidence-based
    • Keep appointments and minimize cancellations
    • Respect the rights, property, and privacy of other DV Therapy Inc clients and staff
    • Report accurate and complete information regarding all matters relevant to treatment
    • Be informed and ask questions regarding your treatment
    • Promptly pay your bills
    • Be an active participant in therapeutic treatment
    • Conduct yourself in a respectful manner

    Remember: Being a good consumer does not mean being a silent partner!

    ASK questions when you have them

    SPEAK UP when you have concerns

    EXPRESS YOUR APPRECIATION when you are satisfied with your treatment

    If you are unsatisfied with your services at DV Therapy, please contact the administrative
    assistant and/or office managers at 323-426-6402 or send them an email. Please allow 24 – 48
    hours for a returned response.

    Bakersfield Los Angeles
    Administrative Assistant Jade Taliulu Michelle Ojeda
    jade@dvtherapy.com michelle@dvtherapy.com
    Office Manager Kristen Turowski, SLPA Etta Astrin
    kristen@dvtherapy.com scheduling@dvtherapy.com


    Palmdale West Covina
    Administrative Assistant Eva Westin Ashley Armendariz
    palmdalescheduling@dvtherapy.com ashley@dvtherapy.com
    Office Manager Rachel Velasquez, SLPA Mariah Prentice, SLPA
    rachel@dvtherapy.com mariah@dvtherapy.com


    Bakersfield
    ABA Clinical Director Daniel Rivera, M.S., BCBA
    daniel@dvtherapy.com

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    7 months ago

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