Play ABA New Client Intake Form (Short Form-Secure)

New Client Intake Form

Instructions: This form is to be completed by the parent/guardian of the individual receiving services, prior to the delivery of services. A copy MUST be retained by Play ABA and the parent/guardian of the client.
Child's Information
Child's Name: *

First Name Last Name
Gender: *

Male Female
Date of Birth: *

Month Day Year
Age: *
Child's primary diagnosis: *
Age diagnosed: *
Other diagnoses (if any):
Who does the child live with?: *
Do you have specific preferences for a provider? (E.g. Male/Female, experience, ability to drive etc.,) *
Which of the following services are you requesting? *

Respite Habilitation Speech
What are the expectations you have for a provider working with your child? *
What is your child's primary language? *
What is your child's primary mode of communication? *
Does your child have any hygiene needs? Such as, toileting, dressing? *
Parent Information (Mother)
Mother's Full Name: *

First Name Last Name
Mother's Email: *

Mother's Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mother's Cell Phone: *

Area Code Phone Number
Mother's Home Phone: *

Area Code Phone Number
Mother's Work Phone:

Area Code Phone Number
Parent Information (Father)
Father's Full Name: *

First Name Last Name
Father's Email: *

Father's Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Father's Cell Phone: *

Area Code Phone Number
Father's Home Phone: *

Area Code Phone Number
Father's Work Phone:

Area Code Phone Number
Emergency Contact
Emergency Contact: *

First Name Last Name
Relationship: *
Cell Phone: *

Area Code Phone Number
Home Phone:

Area Code Phone Number

Statement of Authority to Consent, Permission for Assessment & Treatment Consent Agreements
Statement of Authority to Consent: I certify that I have the authority to represent the above-named client. I legally consent to assessment, release of information, and all legal issues regarding the above named client. Upon request, I will provide Play ABA with proper legal documentation to support this claim. I further hereby agree that if my status as legal guardian should change, I will immediately inform Play ABA of this change in status and will further immediately inform Play ABA of the name, address, and phone number of the person or persons who have assumed guardianship of the above-named client.

Permission for Assessment: I consent to allow the above-named client to participate in assessments including but not limited to behavioral assessment, educational assessment, and/or speech/language assessment given by a Play ABA employee to provide observations, interviews with members of the therapy team whom I give authorization to release information, interviews, observations or direct test/interview results with the above-named client.

Treatment Consent: I consent for treatment included but not limited to behavioral treatment, educational treatment, speech/language treatment to be provided for the above-named client through Play ABA, Play ABA employees, and contracted employees. I understand that the procedures used will consist of manipulating antecedents and consequences to produce improvements in behavior. At the beginning of the treatment, behavior may get worse in the environment where treatment is provided or in other settings. As part of treatment, physical prompting and manual guidance may be used. The actual treatment protocols that will be used have been explained to me by Play ABA staff. I authorize and request the implementation of the treatment procedures. I understand there is an expectation that the above-named client will benefit from this plan, but there is no guarantee that this will occur.

I understand that I may revoke this consent at anytime without penalty and I understand that there is no penalty for refusing to grant this consent. However, I cannot revoke consent for action that has already been taken. A copy of this consent shall be valid as the original. I understand that I have a right to receive a copy of this authorization upon request. I understand what this agreement means.
Statement of Authority to Consent, Permission for Assessment and Treatment Consent Agreement *

I have read and agree to the terms and conditions stated above in the Statement of Authority to Consent, Permission for Assessment & Treatment Consent Agreements

Privacy Statement
Information regarding Play ABA clients, obtained during service provision, is considered private and confidential. However, there are conditions in which this information will be shared with outside agencies/entities.

reimbursement for Deparment of Economic Services/Division of Developmental Disabilities (DES/DDD) services requires disclosure of client information and detailed reports regarding service dates, times, activities, and progress. Unusual incidents and or events that potentially threaten the health or well-being of the client or any minor on the premises must be reported not only to DES/DDD but to appropriate law enforcement agencies.

Play ABA is required to disclose protected health information to the individual (or their personal representatives) at their request and to outside agencies for other reasons covered by law or national security including public health activities, serious threats to health or safety, essential government functions, and/or Worker's Compensation claims.

Client requests must be made by the client or their legal representative in writing to Play ABA for release of information to outside agencies.

Play ABA will use electronic communication and transmission for the purposes of billing, updates on client speciic information, and changes in service eligibility. Individuals or their legal representative may request an alternate method of communication if they so desire.

Individuals or their legal representative who feels their right to privacy has been violated may file a grievance with Play ABA describing the incident and disclosure. Play ABA will respond to all grievances within 10 business days.
Consent to Email *

I authorize Play ABA to contact me through email for both routine communications and for the transmission of private information including billing information, progress reports, or changes in service provision. My signature indicates that I understand and accept the reasonable risks associated with electronic forms of communication.

Photographic Release
Play ABA may acquire and maintain photographic records of the individual listed above. *

I grant Play ABA permission to use my child's photo for the purposes specified below. I deny Play ABA permission to use my child's photo.
Play ABA may include photos of the individual listed above in materials designed to assist Play ABA personnel in finding clients. *

Yes No
Play ABA may display photos of the individual listed above in presentations, on the Play ABA website, or in promotional materials. *

Yes No
Play ABA may display the individual's first name along with photos in presentations or on the Play ABA website. (e.g. achievement award). *

Yes No
Photographic Release *

I understand that by signing below I have either granted or denied Play ABA permission to the above selected conditions regarding the use of my child's photo. I understand that I will not be compensated, now or in the future, for the use of my child's photograph.

Service Agreement
Play ABA will continually recruit, train, monitor and refer individuals qualified to provide DDD services.
Play ABA will collect, maintain, and provide written summaries of monthly billing statements and progress reports.
Play ABA will, at its discretion, provide employee training for medication administration and transportation. Play ABA employees may not administer medications or provide transportation without prior approval of Play ABA.
Play ABA will, within guidelines of DDD, work with the treatment team to establish an individualized program focusing on the unique needs of the service recipient based on the type of service received.
Play ABA may, for any or no reason, remove, suspend, or discontinue employment of any service provider.
In case an emergency arises, I will contact the Play ABA emergency pager line at (602) 356-0298.
I (Client) may refer individuals for employment at Play ABA. However, Play ABA has final authority in all decisions related to hiring, status, and pay rates of its employee.
I (Client) am required to interview and orient all potential service providers who will be working in my home or with the service recipient. I understand that I may, for any or no reason, contact Play ABA to refuse services from any employee.
I must, as soon as possible, communicate any concerns regarding service delivery, program goals/objectives and employee behaviors/actions to Play ABA.
I (Client) may file a written grievance with the Play ABA Client Service Representative regarding any issue and expect a written response within ten working days.
I (Client) understand that Play ABA employees are not permitted to bill Play ABA for Habilitation and/or Respite services over the amount of hours allotted by DDD or outside of the authorization period.
I (Client) must provide any and all training materials, reinforcers, and other items required for special diets or safety concerns.
I (Client) must review and verify the accuracy of all time sheets and data sheets submitted to Play ABA.
I (Client) must thoroughly train all new providers on the special needs of the service recipient and update all providers of changes in the daily routine or needs of the service recipient.
I (Client) may not offer providers additional compensation for DDD services, including reimbursement for transportation. I also understand that Play ABA may not request or expect additional compensastion for the provision of DDD services and that any such requests should be documented in a formal grievance and submitted to the Play ABA Client Services Representative.
I (Client) have been given a copy of the Play ABA Privacy Statement and I understand the contents of that statement.
By signing this document I certify that I am the responsible party for the individual receiving services. I understand that the agency will supply this document and the ISP goals (if habilitation services are indicated) to the Provider.
Service Agreement *

Checking this box indicates that I understand and agree to abide by the described policy set forth by Play ABA.By signing this document I certify that I am the responsible party for the individual receiving services. I understand that the agency will supply this document and the ISP goals (if habilitation services are indicated) to the Provider.

Release of Information
This consent form is to authorize the release of the following information to Play ABA, regarding my child. This release includes all employees and individuals who provide services on a contract basis to Play ABA (i.e. contracted speech therapists, behavior analysts, occupational therapists, music therapists, etc). Permission is also given for the above-named party to discuss issues related to this case with Play ABA, employees and contractors (both parties may disclose and receive information regarding the case).
Permission To Release Information *

Allow classroom/program observation Current IEP and or IPP Behavioral evaluations Psychological evaluations Educational evaluations Medical evaluations None
Release of Information Consent *

I have read the above consent form regarding the release of the above checked off information.

Agreement

By signing below you agree to the terms and conditions set forth in this contract.
Parent/Legal Guardian Name: *

First Name Last Name
Parent/Legal Guardian Signature *

If you are signing using a PC/Mac , sign the box using your mouse. If you are using a tablet, use your finger to sign above. Clear
Should be Empty:

New Client Intake Form

Child's Information

Parent Information (Mother)

Parent Information (Father)

Emergency Contact

School & HCBS Information

Medical & Health Information

Statement of Authority to Consent, Permission for Assessment & Treatment Consent Agreements

Privacy Statement

Photographic Release

Service Agreement

Release of Information

Insurance Coverage: Consent to Bill

Agreement