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WELCOMEDear Parent/Guardian,

On behalf of the staff at the Shabani Institute and Center for Behavior Analysis and Language Development, WELCOME! We are excited to have your child and family join our Center. In preparation for your start date, please read the following information so you know what to expect during your time with us.

For Clinic Based Services:Each day, when you arrive at the clinic, go to the front desk, sign in, and have a seat with your child in the lobby. The therapist(s) assigned to work with your child that day will meet you in the lobby. On the first day, please plan to stay for approximately the first hour and a half to complete consent forms and meet with your child’s therapist. The client’s treatment team typically will consist of 3 main people: 1) a primary therapist, 2) a back up therapist(s), and 3) the Board Certified Behavior Analyst (BCBA).

For Home Based Services:Prior to the initiation of home based behavioral health services, an initial meeting and intake will occur at the clinic. Periodically, behavior sessions may also occur at the clinic. Treatment teams for home-based services are similar to clinic based services.

For Both Clinic & Home Based Services:During the initial week(s) of treatment, we will gather baseline data to establish current levels of skills and problem behaviors. We will evaluate various environmental variables that may be influencing both the skill deficit (or excess) and problem behavior. The baseline data will provide us a benchmark on which to judge improvements or lack of improvements in behavioral performance across time. In addition, it will help us develop hypotheses about why problem behaviors occur under different environmental conditions. This data and these hypotheses assist the treatment team in developing an individualized treatment plan. Each client is different and the treatments developed in our program are individualized for each specific client. We use each client’s behavior, with input from the family, as a guide to make decisions about the next best step in his/her treatment.

Copyright Shabani Institute (August 2012) Do not duplicate without permission

5840 Adenmoor Ave.Lakewood CA 90713

Office: (310) 310-2931Fax: (310) 310-2097

www.shabani-institute.org

Given the number of children receiving behavioral health treatment, it is important to effectively utilize each moment your child is with us. Please plan to arrive promptly for your appointment and departure times. For home-based services, staff is also required to arrive promptly for sessions. Attendance each day is expected, unless your child is ill or has a doctor’s appointment. If your child will be out or late, please call the supervisor of your case or the front desk at 310-310-2931.

Finally, we encourage parents/caregivers/family members to be involved in their child’s behavioral health treatment. You are welcome to watch sessions (from behind a one way mirror or at home) and we anticipate that you will participate in parent training sessions weekly.

We look forward to serving your family and child and look forward to our future work together. If you have any questions or concerns, please contact Dr. Daniel Shabani, Executive Director of the Shabani Institute Center for Behavior Analysis & Language Development at [email protected] or 310-310-2931 Ext. 107.

Sincerely,

Shabani InstituteCenter for Behavior Analysis and Language Development Staff


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mailto:[email protected]


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CHECKLISTThank you for your interest in the Shabani Institute and Center For Behavior Analysis & Language Development (CBALD). Our goal is to provide you with the highest quality ABA service we can provide. To improve our knowledge of your child and family, we request that you complete this entire packet. If you have any questions about completing this packet please contact us at CBALD (310-310-2931 Ext. 101).

In addition, we will need you to provide the following documentation prior. Please let us know if any of the following documentation is not available.

Your child’s:

Individualize Educational Plan (IEP)

Recent report card (if applicable)

Letter of diagnosis (Primary Care Physician or Developmental Pediatrician)

Psychological evaluation

Past and present programs designed to treat any behaviors (e.g., behavior plans)

Any other evaluation reports (e.g., school assessments, functional behavior

assessments, behavior intervention plans)

Comments regarding availability of above materials:

Thank you and we look forward to serving your family.

Daniel B. Shabani, PhD., BCBA-DExecutive Director


5840 Adenmoor Ave.Lakewood, CA 90713

Office: (310) 310-2931Fax: (310) 310-2097


WHAT TO EXPECT ONCE YOU CONTACT CBALD

Activity Timeline Responsible Party

Once you contact CBALD, a representative will contact you to begin the enrollment process.

1-2 days CBALD

If seeking insurance coverage, complete insurance information form1 and return to CBALD.

Indefinite Family

Insurance Authorization for Assessment. 1-7 days CBALDChild/family enrollment packet sent to family. 1-2 days CBALDComplete information packet, provide requested documentation, and return to CBALD.

Indefinite Family

Schedule initial assessment. Based on availability (about 7-21 days)

CBALD

Initial assessment. 1 hour to 3 days CBALDAssessment report completion. About 2-3 weeks CBALDInsurance authorization for therapy. 1-7 days CBALD

Initial team meeting (introduce team, review report and program plan, begin therapy).

1-4 weeks from insurance

authorization or report completion

CBALD

1 Located in enrollment packet.



Office: (310) 310-2931Fax: (310) 310-2097


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HISTORY & BACKGROUND INFORMATIONInstructions: Please answer all of the questions below, even if some may not apply directly to your child. In order to help us more fully learn about your child, you should also bring copies of your child’s recent school report cards, standardized test score results, and any behavioral, educational, medical, and/or psychological reports.

BASIC INFORMATIONChild’s name: Today’s date:

Gender (circle): Male Female Child’s age (years): Grade:

Date of Birth:

Race/Ethnicity (check all that apply): Native American/Alaskan Native Asian Hispanic/Latino Hawaiian/Pacific Islander White African American/Black

Other:

Person completing this form: Select one If other, pleased describe:

Legal guardians: Relation to child: Home address:

Daytime phone: Mobile/Other phone:

Email:

Child’s social security #:

REFERRAL INFORMATIONBriefly describe the reason(s) you have brought your child to CBALD:

Who referred you here: Title: Address: Phone:



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REGISTRATION FORMINSURANCE INFORMATION(PLEASE GIVE YOUR INSURANCE CARD TO THE RECEPTIONIST)Address: Home telephone #: Mobile #: Consent for email communications: Select one Person responsible for bill: Your birth date: Your occupation: Your employer: Is this patient covered by insurance? Select onePlease indicate primary insurance: Subscriber’s name: Subscriber’s social security #: Subscriber’s ID #: Subscriber’s birth date: Group #: Policy #: Patient’s relationship to subscriber: Select one IN CASE OF EMERGENCY CONTACT: Telephone #: Name of local friend or relative: Relationship to patient: Telephone #:

The above information is true to the best of my knowledge. I authorize the Shabani Institute and Center for Behavior Analysis & Language Development to provide my child or myself with reasonable and proper medical care according to today’s standards. I authorize the insurance company or any third party payer to pay any benefits due directly to this office should they accept assignment of my claim. I also authorize the Shabani Institute and Center for Behavior Analysis & Language Development or the insurance company to release any information required to process my claims. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR THE ACCOUNT EVEN THOUGH INSURANCE MAY BE PENDING ON ALL OR A PORTION OF THE CHARGES.

YOUR SIGNATURE2

TODAY’S DATE

YOUR NAME PRINTED CLEARLY RELATIONSHIP TO

INDIVIDUAL

2 Original signature required.



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LANGUAGE & COMMUNICATION How does your child communicate with you (e.g., vocally, gestures, sign language, pointing, writing)?

How does your child tell you when they want something?

Does your child understand basic requests (e.g., come here, sit down)? Select oneIf yes, please list some examples:

Does your child understand complex, multi-step requests (e.g., got to your room, get your shoes, and meet me in the kitchen)? Select one

If yes, please list some examples:

Does your child use an augmentative communication system (e.g., iPad, sign language, PECS)? Select one

If yes, please describe:



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EDUCATIONAL HISTORYChild’s school:

Address: Phone:

Teacher’s name:

Type of Classroom (e.g., special day class, resource, regular education classroom):

Does your child have his or her own 1:1 classroom aide? Select one

Comments regarding classroom aide:

Days & times in school:

Does your child ride the bus to school? Select one

Program specialist/Administrative contact:

EDUCATIONAL BACKGROUND:

Placement (check all that apply):

General Education

Special Education

Classification:

Does your child have (check all that apply):

One-to-one aide Resource classroom

Self-contained classroom Speech-language services

Occupational Therapy services Physical Therapy services

Adaptive Physical Education (APE)

Behavioral Services Day Program

Other, please describe:



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Did teachers report anything special or unusual about his or her early school performance?

Did your child show unusual abilities in any academic area (e.g., reading, math) at an early age? Select one

If yes, please explain:

Has your child changed schools for reasons other than normal academic progression? Select one

If yes, when and for what reason?

Has your child skipped or repeated a grade in school? Select oneIf yes, please explain:


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RECENT SCHOOL PERFORMANCEWhat activities at school does your child most enjoy?

What activities at school does your child least enjoy?

Has your child’s school performance in (or attitude towards) school changed in the last two years? Select one If yes, please explain:

Describe any concerns about social or emotional problems, or other matters that may affect your child’s school functioning:

Please indicate who resides in your home and/or has significant contact with your child:

HOME & SOCIAL INFORMATION

Name Relationship Age Occupation Education Resides with Child

Select one

Select one

Select one

Select one

Select one

Select one

Select one

If parents are separated or divorce, who has custody of the child?

How old was the child when the separation occurred? If you are divorced or separated, how often does the other parent see the child?

Weekly or more often Once or twice a month Several times a year Rarely

Comments:


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About how many close friends does your child have?

None One Two or more Four or more

About how many times a week does your child do things with friends outside of regular school hours? Does your child participate in any extracurricular activities or special organizations?

If yes, please list:

Beyond family what is the age group of the people that your child prefers to be around? Younger Same-age Older Adults

How well does your child relate to children at school?

How well does your child adapt socially to:One-on one situations? Small group situations? Large group situations?

Describe any major stress that might be affecting your child now (e.g., death, divorce, trauma):

Is any legal action currently underway in the family? Select oneIf yes, please explain:

Does your child speak a language other than English at home? Select oneIf yes, what language?

If English is second language, at what age did your child begin learning English?


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CHILD’S MEDICAL HISTORYHas your child been diagnosed with any behavioral, educational, medical, neurological, psychiatric disorder, such as Attention Deficit Hyperactivity Disorder (ADHD), Learning Disorder (LD), Anxiety and Mood Disorders? Select one

If yes, please specify: Who diagnosed your child? When was your child diagnosed?

VISIONDoes your child have any vision problems? Select one

If yes, has his/her vision been corrected with eyeglasses/contact lenses? Select one

HEARINGDoes your child have any hearing problems? Select one

If yes, has his/her hearing been treated? Select oneHas your child ever had ear infections? Select one

If yes, what was the age at the time of the fist infections? Total number of infections: Average duration of infections? Number of infections before age 3: Were tubes inserted in the child’s ears? Select one

If yes, at what age and for how long? Check any of the problems that were present (check all that apply):

Comprehension problems Covered ears with hands when noisy Irritability Language delay Loud television or radio Pain Complaints Speech Problems Talks loudly Other, please describe:

MOTOR COORDINATIONWhich hand does your child prefer for writing or drawing? Select onePlace a check next to any motor behavior on which your child seems awkward or uncoordinated (check all that apply):

Using scissors Using eating utensils Throwing Catching Walking Running

SENSORY STIMULATIONPlace a check next to any areas of unusual sensitivity displayed by your child (check all that apply): Bright light Loud sound

Being touched Other: Is your child allergic to any medicines, foods, or other substances? Select one

If yes, please specify:


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CHILDHOOD ILNESSES Place a check next to any illness or condition that your child has had.

Check if none of the conditions below apply.

Illnesses or Conditions(Check all that apply)

Anemia Encephalitis JaundiceArthritis (juvenile) Epilepsy or seizures Loss of ConsciousnessBleeding problem Fainting MalnutritionBone or joint disease Fatigue (if chronic and

severe)Measles

Broken bones Hay Fever MeningitisCancer Headaches (frequent and

severe) Paralysis

Chicken Pox Heart disease Rheumatic fever

Diabetes Hepatitis Scarlet fever

Diphtheria High Blood pressure (hypertension)

Tuberculosis

Eczema or hives High fever (greater than 104 degrees)

Whooping cough

Other

Please describe:

MEDICAL TREATMENT & HISTORY

Date of most recent medical exam: Pediatrician’s name: Phone #:

If your child has ever undergone an operation or hospitalization, please list problem below (usually an illness), the child’s age, and the medical procedures that were implemented. Problem (or illness) Age Medical procedures during hospitalization


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If your child has ever been treated with prescription medication other than colds and minor infections, please list them below:

Medication Age Reason prescribed

Does any family members have any medical condition that would influence the child’s treatment? Select one

If yes please list relationship and describe how it influences the child’s treatment:

Does any family member have any psychosocial condition that would influence the child’s treatment? Select one

If yes, please explain:

Is there any other information that you think may help us in understanding and working with your child?

SERVICE PROVIDERSCOORDINATION OF CARE

Please list current and past service providers (e.g., physicians, occupational therapist, neurologist):

Name Occupation Phone Email

What are your immediate goals for your child? What would you like us to know about your child? What current communication skills does your child have (e.g., expressive, sign language, PECS, other)? What level of commitment are you willing to make at home for your child to achieve these goals?


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PARENT & FAMILY HISTORYMedical History:

Self Check if none of the conditions below apply.

(Check all that apply) Stroke Seizures Migraines Liver Damage Anemia Diabetes Chronic Pain Chronic Fatigue Asthma Hepatitis Tuberculosis Eating Disorder Cancer Hypertension Cardiac Problems Urinary Tract Infection Thyroid Problems Communicable Diseases Other, please describe: Childhood/Adolescence (prenatal events, childhood diseases):

Comments:

Name of Primary Care Physician (PCP): No PCPConsent for release to communicate with PCP? Select oneFood or drug allergies? Select one If yes, what specific allergies?

Psychosocial History:Spiritual/Religious Affiliation: Education Level: Brief Occupational History: Cultural Influence: Significant Life Events:

Marriage/Family (i.e., martial history, including current/prior marriages/significant relationships; names/relationships with children):



Office: (310) 310-2931Fax: (310) 310-2097


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Family Members Check if none of the conditions below apply.

(Check all that apply) Stroke Seizures Migraines Liver Damage Anemia Diabetes Chronic Pain Chronic Fatigue Asthma Hepatitis Tuberculosis Eating Disorder Cancer Hypertension Cardiac Problems Urinary Tract Infection Thyroid Problems Communicable Diseases Other, please describe:

Comments:

Quality of Life

Do you feel your child’s condition, behavioral challenges, and/or communication difficulties affect your quality of life (please explain)?

Do you feel your child’s condition, behavioral challenges, and/or communication difficulties affect your family life (please explain)?

Do you feel your child’s condition, behavioral challenges, and/or communication difficulties affect your involvement in the community? Are you limited in where you can go and what you can due to your child’s behavior (please explain)?


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AUTHORIZATION TO RELEASE INFORMATIONCompletion of this document authorizes the disclosure and/or use of individually identifiable health information, as set forth below, consistent with the federal Laws (including HIPAA-Health insurance portability and Accountability Act) concerning the privacy of such information.

As Parent/Legal Guardian of: Date of birth:

I authorize personnel (educational and medical) to release information to fill out forms or provide other written information about my child.

Please list individuals or agencies that you authorize to release both educational and/or medical information:

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Agency/Person(s) Requesting Information

Name: Shabani Institute and Center for Behavior Analysis & Language Development

Address: 5840/5834 Adenmoor Ave. Lakewood, CA 90713

Phone Number: 310-310-2931 Contact Person:

Fax Number: 310-310-2097



Office: (310) 310-2931Fax: (310) 310-2097


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Area(s) Of Information Identified For Release:(Check all that apply)

Personal Health Information Ophthalmological Report Speech/Language Evaluation Academic Records Medical Report Occupational Therapy Evaluation Behavioral Information Psychological Report Physical Therapy Evaluation Other:

DurationThis authorization shall become effective immediately and shall remain in effect for one year or unless a different end-date for expiration is designed below.

Your RightsI understand that I have the following rights with respect to this authorization:

I may revoke this authorization at any time. My revocation must be in writing, signed by me, or on my behalf, and delivered to the agencies/person(s) listed above. My revocation will be effective upon receipt, but will not be effective to the extent that the requestor or others have acted in reliance to this authorization, I understand that I do not have to sign this authorization.

Re-Disclosure:I understand that the Shabani Institute and Center for Behavior Analysis & Language Development will protect this information as prescribed by the Family Education Rights and Privacy Act (FERPA) and that the information becomes part of the student’s educational record. This information will be shared with individuals working for SI/CBALD for the purpose of providing safe, appropriate, and least restrictive behavioral health services. I have the right to receive a copy of this authorization.


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NoteBy signing this form I agree to release the Shabani Institute and Center for Behavior Analysis & Language Development from HIPAA responsibilities and hold harmless, for any error that may occur.

PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE

I authorize the release of any medical or other information necessary to process this claim.

I also request payment of government benefits to myself or to the party who accept assignment below.

Parent/Legal Guardian Name:

Parent/Legal Guardian Signature3:

Date:



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PHOTO/VIDEO RELEASEFrom time to time, it may be necessary to take videotape of students for the following purposes:

1. To be used for data collection.2. To be used for training and instruction for preservice and in-service training.3. To be used in presentations or seminars at local, regional, national or

international conferences.

Your consent is necessary for us to use videotapes of your child. UNDER NO CIRCUMSTANCES will identifying personal information (e.g., student names) be used, other than for training and instructional purposes, without seeking additional consent from you.

CHECK ONE, AND SIGN BELOW: I hereby give my permission to SI/CBALD to use videotaped materials from sessions

for the reasons stated above. I further understand that I may revoke this consent at any time except to the extent that the action has been taken thereon.

I hereby give my permission to SI/CBALD to use videotaped materials from sessions for the following reasons (please see descriptions above; check all that apply).

1 2 3 I DO NOT give my permission to CBALD to use videotaped materials from sessions

for the reasons stated above.

Child’s name: Parent/Legal Guardian name: Date: Parent/Legal Guardian signature4:

SI/CBALD representative name: Date: SI/CBALD representative signature5:

4 Original signature required.5 Original signature required.



Office: (310) 310-2931Fax: (310) 310-2097


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HIPAA NOTICE OF PRIVACY PRACTICESIn order to protect the privacy of your health information and your child’s health information, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) protections apply to individually identifiable “protected health information” that is created or received by us and that relates to the past, present, or future physical or mental health or conditions of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to and individual; and that identifies the individual, or for which there is a reasonable basis to believe the information can be used to identify the individual (hereinafter referred to as “protected health information”). This notice of our privacy practice is intended to inform you of the ways we may use your information and the occasions on which we may disclose this information to others.

I. Uses and disclosures for treatment, payment, and health care operationsSI/CBALD may use or disclose your protected health information (PHI) for treatment, payment, and health care operation, purposes with your written authorization. To help clarify these terms, the following definitions apply: PHI: Information in your health record that could identify you. Treatment: Actions we take to provide, coordinate, or manage your health care and other services

related to your health care. An example of treatment is when we consult with another health care provider, such as your family physician or another psychologist.

Payment: Actions to obtain reimbursement for your health care. Health care operations: Activities that relate to the performance and operation of SI/CBALD, such as

quality assessment, business relater matters, audits and administrative services, case management, and care coordination.

Use: Activities within SI/CBALD such as sharing, employing, using, and analyzing information that identifies you or your child.

Disclosure: Activities outside of SI/CBALD, such as sharing, employing, using, and analyzing information that identifies you or your child.

Authorizations: Your written permission to disclose confidential mental-health information. This requires your signature on a specific legally required form.

II. Other uses and disclosures requiring authorizationSI/CBALD may use or disclose PHI for purpose outside of treatment, payment, or healthcare operations, when your appropriate authorization is obtained. In such cases, we will obtain an authorization form you before releasing this information. We will also need your authorization before releasing your child’s program information. This also includes assessment data and the associated written report.

You may revoke all such authorizations (PHI and/or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that we have relied on that authorization for treatment and/or assessment or if the authorization was obtained as a condition of obtaining insurance coverage; the law provides the insurer the right to contest the claim under the policy.



Office: (310) 310-2931Fax: (310) 310-2097


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III. Uses and disclosures without authorization Child abuse and Adult/Domestic Abuse Health Oversight Activities: If SI/CBALD receives a subpoena from a regulation board, SI/CBALD must

disclose any PHI requested by board. Judicial and Administrative proceedings: If you are involved in court proceedings, and we receive a

court order for the private information, SI/CBALD must provide all court ordered information. We will attempt to inform you first. This also applies to situation when disclosure is necessary to arrange for legal services to enforce or defend SI/CBALD’s legal rights.

Serious threat to health or safety of self or others. National security.

A. Patient Rights: IV. Patient’s rights and CBALD’s Duties Right to request restrictions: You have the right to request restriction on certain uses and

disclosures of PHI. However, SI/CBALD is not required to agree to a restriction your request. Right to receive confidential communications by alternative means and at alternative

locations: You have the right to request and receive confidential communication of PHI by alternative means at alternative locations, For example, you can request that your bills be sent to a location other than your home address.

Right to inspect and copy: You have the right to insect and/or obtain a copy of the PHI for as long as the PHI is maintained in the record. SI/CBALD may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. You have the right to inspect and/or obtain a copy of your child’s program, unless we believe the disclosure of the record will be injurious to your health. On your request, SI/CBALD will discuss with you the details f the request and denial process.

Right to amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. SI/CBALD may deny your request. At your request, we will discuss with you the details of the amendment process.

Right to accounting: you generally have the right to receive an accounting of disclosures of PHI. Please ask if you would like SI/CBALD to discuss the details of the accounting process.

To a paper copy: a copy of this HIPAA notice is posted in the office for your review. If you would like to receive a paper copy, pleas inform us.

B. CBALD Duties SI/CBALD is required by law to maintain the privacy of PHI and to provide you with notice of our

legal duties and privacy practices with respect to PHI. SI/CBALD reserves the right to change the privacy policy policies and practices described in this

notice. Unless SI/CBALD notifies you of such changes, however, we are required to abide by terms

currently in effect. If SI/CBALD revises our policies and procedures, we will notify you at your next scheduled

appointment unless you request notification by mail.

C. ComplaintsIf you are concerned that SI/CBALD has violated your privacy rights, or you disagree with a decision we made about access to your records, please discuss it with us; we will work together to resolve this issue. If we cannot reach agreement, SI/CBALD will refer you to someone who can help you. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human services.


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D. Effective Date, Restriction, and changes to privacy policyThis notice will go into effect on July 13,2009. SI/CBALD reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. SI/CBALD will inform you verbally and we will post a written copy of any new notices. You may also request a written copy.

AUTHORIZATION, AGREEMENT AND SIGNATUREI have read the HIPAA Notices of Privacy Practices and understand my rights regarding my child’s Personal Health Information (PHI) And Psychotherapy Notes and how this information will be used, as presented in Privacy Notice.

I consent to the use and disclosure of my PHI/Program information for purposes of treatment, payment, or other health care operations. I understand and agree to the legally imposed required disclosure and the stated office practices, which do not require my signature for disclosure.

Other uses of my child’s PHI/Program Information will require an authorization from me for the specific intention of the disclosure.

CHILD’S NAME:

YOUR NAME:

YOUR SIGNATURE6:

TODAY’S DATE:



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ACKNOWLEDMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES7

I, , have reviewed a copy of this office’s Notice of Privacy Practices.

Signature8:

Date:

For Office Use OnlyWe attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained because (check all that apply):

Individual refused to sign Communications barriers prohibit obtain the acknowledgment. An emergency situation prevented us from obtaining acknowledgment. Other (please specify):

7 You may refuse to sign this acknowledgment.8 Original signature required.



Office: (310) 310-2931Fax: (310) 310-2097


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Patient Bill of Rights and ResponsibilitiesSI/CBALD respects the rights of patients and their families, including cultural, psychological, spiritual, and personal values, beliefs, and preferences.Although these rights are written for the patient, in most cases they also apply to the patient’s family. The term “patient” also refers to other persons served; “family” refers to parent, other family members, guardians and surrogate decision makers.

Your Rights

You have the right to receive individualized, considerate and respectful care in a safe setting.

Care is delivered in a manner and setting intended to preserve your personal dignity.

Care is provided without discrimination as to your race, color, religion, gender, age, sexual orientation, familial status, national origin, genetic information, physical or mental disability, veteran status, or how your bill is paid.

You have the right to effective communication, based on your individual needs. Special services will be given to address your needs, as appropriate. They can

relate to your age, understanding, language, vision, speech or hearing (when available).

You have the right to be involved in decisions about your care. Before and during treatment, whenever medically possible and at discharge. To receive information about your diagnosis and help make the plan for your

care. To be involved in resolving dilemmas about your care. To refuse treatment to the extent permitted by law and to be informed of the

medical consequences of your refusal.

You have the right to agree to your care. Before agreeing to your care, you will understand:

Why the treatment is suggested. What its possible benefits, risks, and side effects are, including what could

happen if refused. What other treatments could be used. What the outcomes are, including those that are unexpected. What limitations on protecting your confidential information are, if any.



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If you do not agree to the recommended treatment, SI/CBALD may do one of these things:

Suggest other ways of treating you and continue to see you. Refer you to another place to get care if possible. In special emergency cases, seek a court order to allow the treatment.

You have the right to know about the staff who treat you. All staff wear name badges to identify themselves. All staff providing your care will introduce themselves to you and describe their

roles.

You have the right to privacy, confidentiality and security. Your personal information is treated in a confidential manner and in accordance

with applicable law. You may refuse to allow observation by anyone not directly involved in your care.

Your personal privacy will be respected to the extent possible in a healthcare setting.

You will make sure that you and your property are safe and secure. You will approve any recording or filming before it happens.

You have the right to review or obtain a copy of your medical record. Your physician may review it with you. If you do now agree with something in your record, you may ask for the record

to be changed in the way allowed by California law. You have the right to access to, request amendment to, and receive an

accounting of disclosures of your health information as permitted by law.

You have the right to be free from mental, physical, sexual, and verbal abuse, neglect and exploitation.

Any allegations are promptly investigated and appropriate action is taken.

You have the right to access protective services. You may ask the social work department for information about state protection

advocacy agencies for children and adults or resources pertaining to domestic violence.

You have the right to choose or refuse to take part in research. Before agreeing to take part, you will understand the research procedures,

expected benefits, possible discomforts and risks, the extent to which your private information will be kept confidential, and any other relevant information. You can withdraw from the study at any time. If you refuse to take part in or withdraw from the study, the care you receive will not be affected.


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If you are over age 18, according to California law, you have the right to make health care decisions in advance or to appoint a health care agent through an advanced directive or to appoint a healthcare agent though an advanced directive.

When necessary to give informed consent, a surrogate may be appointed on your behalf if you are unable to do so. Contact the social work department for more information.

You have the right to be free from restrain, except when it is temporarily necessary to prevent injury to yourself and others. Such emergency restrain is used in a safe manner and with care and respect.

You have the right to receive an explanation for any changes in treatment.

You have the right to speak with someone about your concerns if you are not satisfied with any aspect of your care and are unable to resolve the situation.

Your Responsibilities

SI/CBALD expects patients and families to act in a reasonable and responsible way at all times. You have the responsibility to:

Provide complete and accurate information about your healthcare and any other requested information.

Ask questions when you do not understand what your doctor or other caregivers tell you about your medications and treatments. Express your concerns if you anticipate problems in the following prescribed treatment and if you are considering alternative therapies.

Follow the instructions related to your care plan. Follow the SI/CBALD’s rules and regulations, such as visitor and smoke-free

guidelines. Show respect and consideration for SI/CBALD staff, other patients and their

families and their property. Meet any obligations for payment. Keep appointments, be on time for your appointment, and call as soon as

possible if you cannot keep your appointments. Keep confidential any information regarding another patient that you may hear

or see. Leave valuables at home and bring only those items necessary.


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CONSENT TO ASSESSMENT & TREATMENTI hereby authorize the participation of my Select one or other (please describe relationship: ), (name of patient), and myself, (insert your name) in an applied behavior analysis program with the Shabani Institute (www.shabani-institute.org) and Center for Behavior Analysis & Language Development (www.cbald.org) to learn behavioral strategies for teaching individuals with behavioral difficulties and/or developmental disabilities.

1. I understand that (name of patient) will receive behavioral services from the Shabani Institute and Center for Behavior Analysis & Language Development. Behavioral assessment will involve observation and monitoring of behaviors targeted for treatment. The assessment process may take several weeks, during which time behaviors targeted for treatment will be allowed to occur. Every effort will be made to minimize the risk of injury. I understand that this assessment period is necessary in order to understand the behaviors targeted for intervention and develop a treatment. Once the assessment is completed, treatment options will be discussed with me. In most cases the initial treatment evaluation will be conducted during behavior therapy sessions only.

2. I understand that I may be asked to participate in assessment sessions, and that I will be involved in the process of selecting a treatment. I will be provided with training on how to carry out the treatment and will be asked to participate in treatment sessions in my home.

3. I understand that in order to maintain safety and to provide behavioral treatment it may be necessary to use behavior management procedures that involve physical contact with my son/daughter/conservatee. Interventions that are not appropriate or are ineffective based on behavioral assessment will be discontinued. The philosophy of the behavior treatment team at the Shabani Institute and Center for Behavior Analysis & Language Development is to use the least restrictive means necessary in order to maintain safety.



Office: (310) 310-2931Fax: (310) 310-2097


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4. “Behavior management procedures” are used as part of a comprehensive plan designed to safely manage clients. These procedures are classified into four categories:

a. Transport Procedures: designed to relocate clients safely when they are unwilling to move and/or they are in danger of harming themselves and others. This includes but is not limited to one/two person escort and baskethold escort.

b. Prompting Procedures: designed as a method to deliver instructional tasks, which may involve hand-over-hand physical guidance.

c. Response Reduction Procedures: designed to reduce target problem behaviors. This includes but is not limited to the use of chair time-out, a baskethold, and hands down.

d. Protective Equipment: designed to provide physical protection from injury without restricting movement. This includes but is not limited to kneepads, gloves, and helmets.

5. I understand that it has been determined that my son/daughter/conservatee, may engage/has engaged in behavior that is highly likely to result in physical injury to self or others (i.e., self-injury or aggression), disruption, and/or property destruction. I also understand that it may be necessary to employ programmatic restraint procedures as an attempt to decrease this behavior.

6. Response reduction procedures and protective equipment are only used if necessary and after consultation with the parents/caregivers/conservators, guardians.

7. I understand that these behavioral services will be provided by trained staff who are supervised by a Board Certified Behavior Analyst. I will be kept informed of progress with assessment and treatment, and can request a meeting with the case manager or interdisciplinary team at any time. The Shabani Institute and Center for Behavior Analysis & Language Development have approved all behavioral interventions that will be used.


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8. I understand that I must maintain a professional and objective relationship with Shabani Institute and Center for Behavior Analysis & Language Development staff.

a. I will not discuss my or staff’s personal life.

b. I will not use staff as confidants.

c. I will limit contact with staff to the context of intervention and will use professional language when speaking with the staff.

d. I will maintain a safe and clean environment for staff to work in and around.

e. I will not engage in any threatening or other inappropriate behaviors with staff.

f. I understand that violations of any of the guidelines are grounds for immediate termination of services.

9. I understand that my son/daughter/conservatee is included in the behavioral program because he/she has displayed developmental delays and/or difficulties in one or more of the following areas: cognitive performance, language development, social skills, self-help skills, and/or behavioral functioning.

10. I understand that I am included in the behavioral program because I am interested in applying the principles and techniques I will learn to help my son/daughter/ conservatee. This may include participating in a treatment program (i.e., parent training), participating in school placement meetings, monitoring my son/daughter/ conservatee’s progress and seeking additional consultation as needed.

a. I understand that failing to participate in the treatment program can result in limitations in the gains that can be made with my son/daughter/conservatee.

b. I understand that missing 3 or more treatment sessions, without 24-hour notice to Shabani Institute and Center for Behavior Analysis & Language Development staff, may result in a meeting with the treatment team to discuss the continuation of services.


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11. I understand that the behavioral program will be supervised by a Board Certified Behavior Analyst with specialized training in Applied Behavior Analysis. I understand that the initial training will cover principles of Applied Behavior Analysis that are used to teach behaviors necessary for my son/daughter/ conservatee to function and succeed in different environments. The teaching situation will be designed to maximize my son/daughter/conservatee’s success by the use of procedures such as differential reinforcement, prompts, and rewards for correct responses. All procedures will be described, demonstrated, and practiced.

12. I understand that for maximum benefit to my son/daughter/conservatee, my participation in the behavioral program is essential. I understand that I am expected to: (a) attend all training sessions, (b) practice therapy procedures that are demonstrated, and (c) receive feedback on my therapy technique.

13. I understand that I may invite other family members or professionals who work with my son/daughter/conservatee to attend the training sessions. These individuals are expected to meet all of the requirements listed in the above paragraph (#12).

14. I understand that the behavioral techniques that are taught to me will not necessarily produce observable results during the course of the initial assessment and training period. The short and long-term application of the techniques has proved to be beneficial for other individuals with developmental disabilities. I understand, however, that my son/daughter/conservatee may experience some distress during the implementation of the behavioral program. All efforts will be made to prevent, eliminate, and minimize such negative effects of participation.

15. I understand that the behavioral program will train me to implement basic behavioral treatment methods with my son/daughter/conservatee. I understand that training is an on-going process and that the acquisition and maintenance of my skills will be assured through participation in follow-up consultations. I understand the limits of my knowledge and training and agree not to apply my skills beyond the treatment program of my son/daughter/conservatee.

16. I understand that I have the right to terminate the assessment and behavioral consultation program for any reason.

17. I understand that the Shabani Institute and Center for Behavior Analysis & Language Development has the right to terminate the assessment and behavioral program for any reason.


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18. I understand that the Shabani Institute and Center for Behavior Analysis & Language Development will make every effort to identify services or make referrals to other services that are not provided by the Shabani Institute and/or Center. Referrals for other services will be determined through consultation with the families Regional Center and/or school district.

19. I understand that although I am allowed to videotape or audiotape the assessment and behavioral programs, these recordings may be used only by me and by my treatment team for the benefit of my son/daughter/conservatee. I agree NOT to sell or otherwise distribute these tapes without the written consent of the Executive Director of the Shabani Institute and Center for Behavior Analysis & Language Development .

20. I have agreed to release my son/daughter/conservatee’s medical and psychological records to the Shabani Institute and Center for Behavior Analysis & Language Development. Releasing these records will allow the consultant to review my son/daughter/conservatee’s diagnosis, developmental, medical, and family history, and levels of intellectual, behavioral, and social functioning.

21. I understand that all reports and records pertaining to my son/daughter/ conservatee and this behavioral program will be kept in a locked file in a confidential manner. I understand that no information that identifies my son/ daughter/conservatee or me will be released without my written consent, except as exempted by law.

22. I have read and understand the above information fully and agree to the conditions. I will be provided with a copy of this consent form.

SON/DAUGHTER/CONSERVATEE’S NAME

YOUR NAME TODAY’S DATE

YOUR SIGNATURE9

RELATIONSHIP TO INDIVIDUAL

WITNESS NAME TODAY’S DATE

WITNESS SIGNATURE10 TODAY’S DATE



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CONSENT TO VIDEO CONFERENCING11

Child’s Name: Date of Birth: Address: Daytime phone: Mobile/Other phone:

I hereby consent to using live videoconferencing services provided by the Shabani Institute and Center for Behavior Analysis & Language Development (SI/CBALD) as part of its behavioral health treatment program. I understand that these services may involve the communication of my health information, both orally and visually, to health care practitioners. Specifically, I understand that videoconferencing services include, but are not limited to, consultation, treatment, and transfer of health data using interactive audio, video, or data communications. I also understand that no data or health information will be recorded, stored, or archived from these live videoconferencing services.

I further understand the following with respect to use of SI/CBALD’s videoconferencing services:

1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment; nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

2. The laws that protect the confidentiality of my health information may also apply to these services. As such, I understand that the information disclosed by me during any videoconference session is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality.

3. There are risks and consequences from use of these services, including, but not limited to, the possibility, despite reasonable efforts on the part of SI/CBALD, that the transmission of my health information could be disrupted or distorted by technical failures and/or the transmission of my health information could be intercepted or accessed by unauthorized persons.

4. I have a right to access my health information and copies of health records in accordance with HIPAA privacy rules and applicable state law.

11 This document is not a HIPAA Privacy Authorization form nor should it be interpreted as such. This consent form applies only to video conferencing services provided by SI/CBALD as part of its behavioral health treatment program. SI/CBALD has a separate HIPAA Privacy Authorization Form.



Office: (310) 310-2931Fax: (310) 310-2097


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I have read and understand the information provided above. I have discussed it with representatives from SI/CBALD, and all of my questions have been answered to my satisfaction.

Signature of patient/parent/guardian/conservator12:

Date:

Relationship to child:

Signature of SI/CBALD Representative13:

Name of SI/CBALD Representative:

Date:



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