ABA2DAY BEHAVIOR SERVICES
606 E Baltimore Pike, 2nd Fl
Media, PA 19063
 
ABA2DAY BEHAVIOR SERVICES WEST
3744 West Chester Pike Newtown Square, PA 19073
 
General Question:
610-864-7376
Hiring:
484-620-0943
Scheduling:
610-203-1508
Fax:
877-599-3340

General Intake Online Form

Dear Parents/Guardians,

Thank you for expressing interest in ABA2DAY Behavior Services, LLC.

The first step in enrolling in our program is completing the necessary paperwork for your child. Please thoroughly fill out each page of the intake packet attached to this letter. Once you have completed the forms you may submit them by mail, fax, e-mail, or arrange to drop them off at one of our centers. In addition to the intake packet, please complete the waiver packet and submit any supporting medical/educational documentation and a copy of the front and back of your insurance card. Please also note that forms can be filled out on our website by visiting myaba2day.com.

Thank you for taking the time to thoroughly complete our general intake and waiver forms. We ask for as much information as possible to better serve you and your child. Please do not hesitate to contact us at any time during the intake process if you have any questions.


Sincerely,

The ABA2DAY Administrative Team

Please Included the Following Documents: (If Available)

 
Intake Form  
Copy of Most Recent IEP / IFSP  
Confidentiality Release Form  
Most recent comprehensive evaluation  
Educational Evaluation Report (Original Copy)  
Medical Diagnostic Report (Original Copy)  
Copy of most recent Speech / Occupational Therapist Evaluations and Goals  
Completed Weekly Schedule Form.  
A "Preferred" Schedule (including center-based, home, school, community and accommodations).  
Copy of Medical Insurance Card (front and back)  
Interest in joining, social skills, inclusion, school readiness and play skills in groups  
Interested in small group sessions of 2 or 3  
*Please note that if you do not have all of the information on this list, you may still move forward with the application process as long as you provide a copy of your insurance card (back & front) and the general information of this packet completed.

Name of Person Completing Form:
Relationship to Child:
Today's date:
CLIENT INFORMATION
Full Name:
Preferred Name:
Date of Birth:
Male or Female:
DIAGNOSIS INFORMATION
Educational Diagnosis:
Diagnosed by whom:
Date of Diagnosis:
Age at time of diagnosis:
Medical Diagnosis:
Diagnosed by whom:
Date of Diagnosis:
Age at time of diagnosis:
PRIMARY CARE PHYSICIAN INFORMATION
Name:
Phone: Fax:
Address:

FAMILY INFORMATION
Parent information
Parent's Name:
Address
Street:
City: State: Zip Code:
Name of Employer: Occupation:
Home Phone(If Different from Application): Business Phone:
Cell Phone:
Fax:
Email Address:
Parent information
Parent's Name:
Address
Street:
City: State: Zip Code:
Name of Employer: Occupation:
Home Phone(If Different from Application): Business Phone:
Cell Phone:
Fax:
Email Address:
Guardian information
Full Name: Relationship to Child
Address(If Different from Application)
Street:
City: State: Zip Code:
Name of Employer: Occupation:
Home Phone(If Different from Application): Business Phone:
Cell Phone:
Fax:
Email Address:

Initials of Family Information:

Sibling Information
Name: Age: Gender:


Medical History
Does your child have/had any of the following conditions:
Hearing Lose
Seizures
Yes No
Vision or Eye Problems
Sleep Problem
Yes No
Allergies
Tics/Movement Disorders
Yes No
Chronic Bowel Issues
Genetic Disorders
Yes No
Multiple Ear Infections
Depression
Yes No
Frequent or Chronic Headaches
ADHD/ADD
Yes No
Head Abnormalities
Obsessive-Compulsive Disorder
Yes No
Chronic Heart Conditions/Disease
Anxiety
Yes No
Lung Disease(Asthma, other)
Schizophrenia
Yes No
Chronic Skin Problems
Mania/ Bipolar Disorder
Yes No
Hormone/ Growth Problems
Other Psychiatric Illnesses
Yes No
Criminal History
Other:
If Yes to any, please explain:

Initials of Medical History:

PRENATAL/ BIRTH/ DELIVERY HISTORY
DUE TO INSURANCE GUIDELINES ABA2DAY IS REQUIRED TO ASK THE FOLLOWING QUESTIONS:
Were fertility treatments used
Was there proper prenatal care?
Did mother use drugs, tobacco, or alcohol during pregnancy?
Was mother hospitalized during pregnancy?
Mother's age at birth of child?
Describe any complications during pregnancy:
Describe any complications during delivery:
Type of Delivery:
Was child born on time?
Weeks early or late?
Child's birth weight
Did child experience any problems while still in hospital?
Was child placed in NICU?How long?

Initials of this page:

 Medical information:
 Is your child currently taking any medications:    
 If you answered "Yes", Please list the Medication(s), Dosage, Administration Times and
 Purpose Below.
 Name of Medication:  Dosage:  Administration Times:  Purpose:

Please list any Dietary Restrictions
 Has your child ever been admitted into a hospital / treatment center for psychiatric, behavioral or crisis situations? (If "Yes", Please Explain)

ALLERGY CHECKLIST
Allergy: Allergy: Allergy:
Pollens
Milk
Penicillin
Molds
Eggs
Antibiotics
Dust mites
Fish
Sulfa drugs
Animal
Crustaceans
Barbiturates
Feathers
Mollusks
Anticonvulsants
Insect venom
Wheat
Insulin
Kapok
Nuts
Novocain
Wool
Fruits
Lodine
Smoke
Chocolate
Caine anesthetics
Perfume
Sugar
Physical agents
Nitrate
Latex
Sulfates
Other:


Emergency Contact Information
Full Name:
Relationship to Child:
Address:
City:
State:
Zip Code:
Name of Employer:
Occupation:
Cell phone:
Home phone:
Email Address:

GENERAL INFORMATION
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?
(ex. Sign language, PECS, verbal...) Please be Specific.

Are you willing to implement programs at home?

THE UNDERSIGNED HEREBY ACKNOWLEDGES THAT THE INFORMATION CONTAINED IN THES APPLICATION IS ACCURATE AND TRUE TO THE BEST OF HIS/HER KNOWLEDGE.
Parent/Guardian(Print Name):
Parent/Guardian(Sign Name):
Date(MM/DD/YYYY)

Supportive Services:

What other service(s) is your child currently receiving, both in-school and out of school?
(Please enclose a copy of the child's most recent IEP or IFSP and therapy goals from each area that is checked).
Service / Therapy: Location: Minutes per Week:
Early Intervention Services School - Home
Speech and/or Language Therapy School - Home
Occupational and/or Physical Therapy School - Home
Vision Services School - Home
Hearing Services School - Home
ADP Behavior Services School - Home
Counseling School - Home
Academic Tutoring School - Home


EDUCATIONAL HISTORY
Is your child currently enrolled in school/Daycare?
Name of School/Daycare:
District:
Current Grade Level:
Does your child's teacher have any concerns about him/her that you would like to address?
If yes, please explain.

If your child is in Special Education, do they have:
504Plan
IFSP/IEP
Psychological Evaluation
Speech Evaluation
Behavior Intervention Plan
Occupational Therapy Evaluation
Physical Therapy Evaluation
Adaptive Technology Evaluation
Please rate your level of satisfaction with your current educational program:
Rating scale 1-10 with 1 being very dissatisfied and 10 being very satisfied. Please explain below:
Please list any extracurricular activities that your child is involved in:
Please describe your child's history of special education:
Ex: amount of inclusion, autism and learning support. History of past ABA service, etc.

Do you have any concerns in any of the following areas?
Responding to sound
Responding to touch
Responding to light
Emotional reactions/regulation
Aggression towards others
Self-injurious behavior
Difficulty with transitions
Understanding social cues(e.g. gestures, facial cues)
Eye contact
Inappropriate conversations
Other inappropriate behavior
Ritualistic behavior
Repetitive behavior(e.g. hand flapping, rocking)
Fixation(e.g. computers, certain TV program, watching spinning toy)
Toileting
Academics
Social skills
Play skills
School readiness

SCHEDULES
Current School/Therapy Schedule:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Desired ABA2DAY Schedule
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Service Location Preference: Please choose all that apply In-Home Therapy
Center Based Therapy
School
Requested Therapy hours per week: Requested Therapy hours by diagnosing physician per week:
Location Preference for center based Media
Newtown Square
PLEASE NOTE THAT ALL TIME AND LOCATION REQUESTS WILL BE TAKEN INTO CONSIDERATION. WE HIGHLY
RECOMMEND FOLLOWING THE CLINICAL OPINION OF ABA2DAY'S CONSULTANTS.

Child's Name:
DOB:
Today's date:
Completed by:
Edible Reinforcers
Candy Yes No
Cereal Yes No
Juice Yes No
Soda Yes No
Milk Yes No
Chips Yes No
Cookies Yes No
Fruit Yes No
Ice Cream Yes No
Pretzels Yes No
Popcorn Yes No
Gum Yes No
Jell-O/Yogurt Yes No
Activity Reinforcers
Taking a walk Yes No
Color/Paint/Drawing Yes No
Play Dress Up Yes No
Story Time Yes No
Board games/Puzzles Yes No
Computer/Electronics Yes No
TV/iPad Yes No
Craft activities Yes No
Outside play Yes No
Climbing Yes No
Hide and Seek Yes No
Being class helper Yes No
Sensory Reinforcers
Water Play Yes No
Bubbles Yes No
Rocking Yes No
Jumping/Trampoline Yes No
Quiet Time Yes No
Listening to music Yes No
Swinging Yes No
Shaving Cream Yes No
Flashlight Yes No
Shiny objects Yes No
Play Doh Yes No
Spinning/Squeaky objects Yes No
Social Reinforcers
Adult/Peer attention Yes No
High fives Yes No
Singing Yes No
Parties Yes No
Hugs Yes No
Tickling Yes No
Verbal Praise Yes No
Back Scratch/Rub Yes No
Smiling Yes No
Break from adults/peers Yes No
Clapping Yes No
Other Highly Preferred Items: Additional Comments:

I, do hereby authorize ABA2Day Behavior Services, LLC., its agents and associates, to REALEASE TO and OBTAIN FROM information, from the record of:

(Print Child's Name):

(Child's Date of Birth):


Said information that may be released, includes, but is not limited to, the following:
Physical Examination Progress Notes
Birth Record Summary of Treatment to Date
Medical Examination Discharge Summary
Psychological Examination After Care Plan
Psychosocial History Records of Medication
IEP/IFSP Records of Education


By signing below, I accept and acknowledge that I will not have to provide further consent to ABA2Day Behavior Services, LLC., its agents and associates, for the release of this information. By signing below, I understand that I am providing ABA2Day Behavior Services, LLC., its agents and associates, the right to obtain any information about my child, for the purpose of his/her treatment, as described within. I acknowledge that I am signing this agreement willingly and voluntarily.
Further, I understand and acknowledge that I may revoke this authorization at any time, except to the extent that action has been taken in reliance thereon, and that said authorization may only be revoked by contacting the Director of ABA2Day Behavior Services, LLC., by written communication, and that said communication must be dated.


(Signature of Parent Guardian) (Date)
I have Requested a Copy of this Release
I have waived my right to a Copy of this Release

 AGREEMENT FOR PAYMENT OF SERVICES
 
This AGREEMENT is entered between ABA2DAY Behavior Services, LLC ("ABA2DAY") on the one hand, and the party or parties whose name(s) appear(s) at the end of this AGREEMENT (the "Obligated Party") on the other.
 
In consideration for ABA2DAY providing Applied Behavior Analysis ("ABA") or Special Instruction ("SI") services and such other services as are requested or required of ABA2DAY (the "Services"), including but not limited to (a) program development, (b) supervision of therapists, (c) one-on-one meetings; (d) two-on-one meetings, (e) group meetings, (f) in-person and/or telephonic consultation with parents or guardians or teachers, (d) recruitment and training of therapists, (e) Individualized Educational Plan ("IEP") meetings and preparation for same, (f) Individual Family Service Plan ("IFSP") meetings and preparation for same, (g) transitional meetings and preparation for same, (h) progress reports, (i) data review, for or on behalf of the child whose name appears below (the "Child"), and for other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the Obligated Party agrees as follows:
 
1. The Obligated Party warrants to pay all reasonable fees charged by ABA2DAY for Services. The Obligated Party warrants that if ABA2DAY is required to travel in excess of 30 miles in the provision of Services, the Obligated Party will reimburse ABA2DAY for all its mileage at the current IRS reimbursement rate, as well compensate ABA2DAY at the hourly rate of theprofessional traveling to provide Services, rounded to the nearest one-quarter hour. The Obligated Party separately warrants to reimburse ABA2DAY for all incidental fees incurred on behalf of the Child in the provision Services, including but not limited to community outings.
      
a. If the Obligated Party is a private-pay client, the Obligated Party is required to pay ABA2DAY for Services to the Child within 30 days of the date of service.
 
  b. If the Obligated Party has insurance applicable to the Services provided by ABA2DAY and accepted by ABA2DAY, or a County or other municipal or governmental or administrative agency has agreed to reimburse ABA2DAY for the Services provided to the Child, the Obligated Party agrees to pay all deductibles and co-pays associated with the provision of Services to the Child, in addition to all sums for Services to the Child for which the third-party payor (i.e., the insurer, County, municipality, etc.) declines to make payment or for which the third-party payor does not otherwise authorize the provision of Services.
 
      
i. All deductibles are due in full at the time that Services are provided.
 
  ii. All sums for Services for which an Obligated Party's third-party payor declines payment and/or coverage are due within 30 days of the date of ABA2DAY's invoice to the Obligated Party.
 
(Initials of Obligated Party:)

2. If Obligated Party fails to pay ABA2DAY for any Services for which payment from the Obligated Party is due, ABA2DAY may commence an action or other proceeding against the Obligated Party (the "Action"). If ABA2DAY prevails in the Action, Obligated Party shall be obligated to pay all of ABA2DAYs reasonable attorneys fees incurred in pursuing and collecting the sums owed to ABA2DAY from OBLIGATED PARTY. This provision is without limitation to ABA2DAYs right to collect other fees, costs, and sums in the course of the Action, to the fullest extent permitted by law.
 
3. Obligated Party warrants that they understand that the rates charged by ABA2DAY for Services generally increase at the start each near year; ABA2DAY will provide thirty days notice to Obligated Party prior to any rate increase.
 
4. This is the full and complete agreement between ABA2DAY and the Obligated Party governing the payment of Services provided through ABA2DAY. There are no other agreements between ABA2DAY and the Obligated Party, express or implied, governing the payment of Services provided by ABA2DAY.
 
5. A waiver on the part of ABA2DAY to enforce the terms of this AGREEMENT on any occasion, shall not be a waiver of the right of ABA2DAY to enforce the terms of this AGREEMENT on any other occasion. Moreover, no sum due to ABA2DAY shall be deemed forgiven by ABA2DAY, except by a writing signed by Alonna Marcus on behalf of ABA2DAY
 
6. This AGREEMENT may not be modified except by a writing signed by Alonna Marcus on behalf of ABA2DAY and the Obligated Party. No person or entity other than Alonna Marcus on behalf of of ABA2DAY shall be authorized to modify this AGREEMENT on behalf of ABA2DAY.
 
7. The Obligated Party represents that they have read and fully understand the terms of this AGREEMENT, and that they willingly accept the terms of this AGREEMENT. The Obligated Party agrees that the terms of this AGREEMENT are fair and reasonable, and are not unconscionable in any way.
 
8. If any term or terms of this AGREEMENT is held to be invalid for any reason, the remaining terms of this AGREEMENT shall remain in full and force and effect.
 
9. Neither ABA2DAY nor the Obligated Party shall be considered to be the drafter of this AGREEMENT, nor any term thereof. No presumption shall be made against ABA2DAY nor the Obligated Party as the Drafter of this AGREEMENT nor any of its terms.
 
10. The Obligated Party warrants that they will not to seek to independently hire any therapist they are introduced to through ABA2DAY for at least one year following the last date of any Service provided by that therapist on behalf of the Child, through ABA2DAY.
 
Initials of Obligated Party:
 
Date

The Child referred to in this AGREEMENT is
 
The Obligated Party is of the child
 
The Address of the Obligated Party is
 
The telephone number of the Obligated Party
 
THE OBLIGATED PARTY AGREES TO BE BOUND BY THE TERMS OF THIS AGREEMENT
 
Name of Obligated Party:
 
Signature of Obligated Party:
 
Date:
CONSENT FOR ABA TREATMENT
 
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 will be reviewed separately.
 
I, agree to have my child/dependent, , participate in applied behavior analysis (ABA) assessment or treatment services provided by ABA2DAY Behavior Services, LLC(ABA2DAY). 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. If these services have been arranged or will be paid for by a third party (e.g. school, insurance plan, state agency), I am aware that third party has the following rights: determination of services, implementation of services, access to documentation of sessions for billing purposes, access to assessment results and written reports. I also understand that my child/dependent is the primary client of the behavior analyst and that services will be designed primarily for ’s benefit. Any other individual or agency (e.g. family, school professionals, etc.) who may be affected by the ABA services are considered secondary clients.
 
If the ABA services focus on increasing ’s skills, I understand that 3-8 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 behavior problems, 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 in other ways. This process may take 1-4 weeks prior to implementing intervention, but will increase the likelihood of effective intervention.
 
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 instruction 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.
(Initials of Obligated Party:)
Full participation (including but limited to: attendance and participation in client sessions, parent training sessions,parent and team meetings, review of data, and data collection) in these implementation and training activities is critical for a successful outcome. If there is evidence of repeated lack of involvement, ABA2DAY reserves the right to revisit and reconsider the appropriateness of services. 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. When services are no longer necessary or appropriate due to age, skill level, or other reason, we will discuss the discontinuation of services. 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 for the client. 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 ABA2DAY 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 others.
 
I understand that the provider agency employs/contracts with individuals at ABA2DAY that are supervised by a Board Certified Behavior Analyst (BCBA). I understand that ’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 at ABA2DAY. All individuals attending these staff meetings are bound by the same confidentiality guidelines as ABA2DAY Behavior Services in order to protect the privacy and that of my child/dependent. 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 reserve the right to withdraw at any time from these services, and I understand that such a withdrawal will not affect ’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 the provider and client is a professional one that precludes ongoing social relationships, giving of gifts, or participation in personal events such as parties, graduations, etc. In addition, I understand that I (or a designated caregiver with written consent) must be present for all sessions conducted in the home or community setting. I understand that I am responsible for adhering to the payment arrangements, attendance, and cancellation policy set forth in a separate document.
 
These policies have been fully explained to me, and I fully and freely give my consent and permission for my child/dependent.
 
Signature of Obligated Party:
 
Date:

 ABA2DAY Behavior Services LLC
Waiver of Consent to Release Medical Information
 
Parent/ Legal Guardian of minor child/ward give permission to ABA2DAY Behavior Services LLC and staff, to speak to as well as share medical records and/or all documentation with any doctors, teachers, therapist, and/or any health professionals involved in the services of my minor child/ward in relation to my minor child/ward. I understand that ABA2DAY Behavior Services LLC meets the requirements for federal Health Insurance Portability And Accountability Act(HIPPA), in regards to EIP(Early Investigation Program) records dealing with billing and claiming.
 
By sign his waiver, I give permission for ABA2DAY Behavior Services LLC and staff, to share documentation, confide in and speak with any doctors, teachers, therapists and health professionals that have in the past and/or present time are involved in the services of my minor child/ward. By signing this waiver I authorize the release of any medical and/or other information necessary to and from any doctors, teachers, therapists and health professions that have in past and/or present time been involved on the services regarding my minor child/ward.
 
By sign his waiver, I lose the right to bring about any claim against ABA2DAY Behavior Services LLC and Staff, if records of any kind are shared and/or released between ABA2DAY Behavior Services LLC, and any doctors, teachers, therapists and health professionals that have in the past and/or future been involved in the services of my minor child/ward.
 
By signing below, I verify that I have read and understand everything in this waiver/form and agree to the terms and conditions. I also validate that I am true parent/legal guardian of the minor child/ward listed below.
 
Childs Name: 
 
 
Parent/Legal Guardians Printed Name: 
 
 
Parent/Legal Guardians Signature:   

Date (MM/DD/YYYY)
 
 
WAIVER OF LIABILITY
PERMISSION TO TRANSPORT MINOR CHILD
 
I give permission for my minor child/ward to be transported in a motor vehicle driven by an ABA2DAY Behavior Services, LLC(ABA2DAY) staff member to and from related activities.
 
I understand that I will be will be waiving my rights to all claims for injuries my minor child/ward might sustain arising out of being transported by an ABA2DAY staff member. I understand that by allowing my child to be transported by a member of the ABA2DAY team, my child may risk personal injury or permanent loss. I hereby verify that I have been informed of the potential risks and fully acknowledge the risks involved in this activity.
 
I hereby assume any expenses that may incur in the event of the accident, illness, or other incapacity, regardless of whether I have authorized such expenses. As a condition for the transportation received, I, for myself and my minor child/ward further agree to release and forever discharge all ABA2DAY staff from any claim that I might have myself or that I could bring on my child/wards behalf with regard to any changes, demands, or action whatsoever arising out this transportation.
 
I have read this entire waiver and permission form, fully understand it, and agree to be legally bound by its terms.
Child's Name:
 
Parent/Legal Guardian's Printed Name:
 
Parent/Legal Guardian's Signature:
 
Date:
WAIVER OF LIABILITY
PERMISSION TO TRANSPORT MINOR CHILD
 
I give permission for my minor child/ward to be transported in a motor vehicle driven by an ABA2DAY Behavior Services, LLC(ABA2DAY) staff member to and from related activities.
 
I understand that I will be will be waiving my rights to all claims for injuries my minor child/ward might sustain arising out of being transported by an ABA2DAY staff member. I understand that by allowing my child to be transported by a member of the ABA2DAY team, my child may risk personal injury or permanent loss. I hereby verify that I have been informed of the potential risks and fully acknowledge the risks involved in this activity.
 
I hereby assume any expenses that may incur in the event of the accident, illness, or other incapacity, regardless of whether I have authorized such expenses. As a condition for the transportation received, I, for myself and my minor child/ward further agree to release and forever discharge all ABA2DAY staff from any claim that I might have myself or that I could bring on my child/wards behalf with regard to any changes, demands, or action whatsoever arising out this transportation.
 
I have read this entire waiver and permission form, fully understand it, and agree to be legally bound by its terms.
 
Child's Name:
 
Parent/Legal Guardian's Printed Name:
 
Parent/Legal Guardian's Signature:
 
Date:

 ABA2DAY Behavior Services LLC
Waiver and Release by Parent of Minor Child/ Ward
 
I, parent/legal guardian of minor child/ward hereby waive and release ABA2DAY Behavior Services LLC, and any staff affiliated with ABA2DAY Behavior Services LLC of and from any and all claims, demands, debts, expenses, cause of action, lawsuits, damages and liabilities of every kind, whether known or unknown in law or on equity that I or my minor child/ward may have arising from in any way related to my minor child/ward's participation in any of the events or activities conducted by, on the premises of, or for the benefit of ABA2DAY Behavior Services LLC.
 
I understand that that the activities and functions that my minor child/ward will participate in may be inherently dangerous and may cause serious injuries, including bodily harm, damage to personal property and/or personal loss. My minor child/ward and I waive all claims and damages, injuries and death sustained to my minor child/ward pr my property that minor child/ward or I may have, while on the premises of ABA2DAY Behavior Services LLC.
 
By signing this waiver, I give permission foe my minor child/ward to participate in activities at/in the building maintained by ABA2DAY Behavior Services LLC at the location 441 E. State Street, Media Pennsylvania 19063. I hereby waive ABA2DAY, its staff, landlord and all parties associated with ABA2DAY of all claims, debts, expenses, lawsuits and liability while my minor child/ward is present in the building of ABA2DAY Behavior Services LLC at 441 E. State Street, Media Pennsylvania 19063.
 
By signing below I arrest that I am the parent/legal guardian listed below, and have read and understand all information given to me in this form/waiver.
 
Minor Child/Wards Name: 
 
Parent/Legal Guardian name (Printed): 
 
Parent/Legal Guardians Signature:   

Date (MM/DD/YYYY)

 ABA2DAY Behavior Services LLC
Acknowledgment of Risk and Waiver of Liability and
Authorization to Seek Medical Attention
 
I, parent/guardian of minor child/ward, understand that in consideration of using the facilities, climbing walls, and equipment at ABA2DAY Behavior Services LLC there is potential risk such as death, injury and damage to property.
 
In the event that such as injury occur to my minor child/ward I release from liability and hold harmless ABA2DAY Behavior Services LLC and any staff associated with ABA2DAY. I discharge and promise not to take legal action any ABA2DAY staff, and its landlord in event that such an injury occurs.
 
In the event of accident or injury, when parent/legal guardian or emergency contact are not available, I give my permission to ABA2DAY Behavior Services LLC to seek medical attention.
 
By signing below I hereby acknowledged that I have read this waive and release thoroughly and understand the terms.
 
Signature of Parent/Legal Guardian: 
 
Print name of Parent/Legal Guardian: 
 
Phone: 
 
Print name of Child: 
 
Print name Emergency Contact: 
 
Phone: 

 ABA2DAY Behavior Services LLC
Photography Release For Minor Child
 
I hereby give ABA2DAY Behavior Services LLC(ABA2DAY) and staff permission to use a photograph(s) as well as video(s) taken of my minor child/ward for use in ABA2DAY's printed publication, website, as well as any social media site in relation to ABA2DAY.
 
I acknowledge that since participation in any publications and website produced by ABA2DAY is voluntary. Therefore my minor child/ward nor I will receive financial compensation. I further agree to waive all rights of ownership, as well as to inspect and/or approve the finished photograph(s)/video(s), advertised copy, or printed matter in which the photograph(s) and video(s) are used.
 
I release ABA2DAY ans staff from any expectation of confidentiality for the undersigned minor child/ward and myself and arrest that I am the parent/legal guardian of the child listed below. By signing below I verify that I have read and understand all information given to me in this waiver/form.
 
Minor Child/Wards Name (Printed): 
 
Parent/Legal Guardians Name (Printed): 
 
Parent/Legal Guardians Signature: 
 
Date (MM/DD/YYYY)
 
PEANUT FREE ZONE
Dear Parent(s),
This leter serves to inform you that some of the students whoattend sessions at our ABA2DAY Behavior Services, LLC centers have severe peanut/nut allergies. It is important that there is a strict avoidance to this food in order to prevent a serious life-threatening allergic reaction. We are asking for your help to provide all children with a safe center based environment.
 
Any exposure to peanuts/nuts may cause a life-threatening allergic reaction that requires emergency medical treatment. To reduce the chance of this happening, we are asking that you DO NOT send any peanut/nut containing products with your child that will be eaten at our center. If your child has consumed peanuts before being dropped off at the center, please ensure that their hands and face have been thoroughly washed before entering the center.
 
We appreciate your cooperation to keep all of our kids safe. Please complete and return this form so that we are certain you have received this information. Please contact us at 610-356-4749 if you have any questions.
 
Thank you,
ABA2DAY Administrative Team
--I have read and understand the peanut/nut free center procedures. I agree to do my part in keeping the classroom peanut and nut free.
Child's Name:
 
Parent/Legal Guardian's Printed Name:
 
Parent/Legal Guardian's Signature:
 
Date:
ABA2DAY CULTURAL AWARENESS QUESTIONNAIRE
At ABA2DAY Behavior Services, LLC, we feel that it is critical that we recognize individual differences. People and families may have different beliefs and practices and we feel it is important to understand the particular circumstances of each family. To do this, we would like to gather some information from you. The following questions will be useful to use so that we are aware of and respect your cultural and religious beliefs. Please note that this form is VOLUNTARY. Please leave questions blank that you wish to not answer.
1. What primary language is spoken in the home?
2. Dose your family have any dietary restrictions? Are there times during the year when you change your diet in celebration of holidays?
3. Please describe your beliefs and practices including special events such as birthdays or holidays that we should know.
4.Do you have any traditional health remedies that you feel we should know?
5.Are there certain health care procedures and tests which your culture prohibits?
6. Are there any other cultural considerations we should know about when it comes to providing services in your home?


Child's Name:
 
Parent/Legal Guardian's Signature:
 
Date:
INSURANCE INFORMATION AND AUTHORIZATION FORM
 
Many health insurance companies cover a portion of the cost of ABA therapy sessions and some additional testing and assessments. However, as insurance benefits have become increasingly complex, it is often difficult to determine exactly what mental health benefits are available. Some plans also require authorization before they will allow reimbursement. Thus, it is very important that you find out from your insurance company what services are covered and if preauthorization is required. We will assist you in the proper billing of your insurance company. Our office will attempt to check your insurance coverage, but we are not always given accurate information. In all cases, you are responsible that your account is paid in full.
 
Your contract with your health insurance company may state that your mental health coverage is limited to "medically necessary" services. Each insurance company has its own definition of medical necessity. For ABA therapy to be covered by insurance, there must be an Autism Diagnosis. If your condition does not meet their definition, your services might not be covered.
 
NOTE: INSURANCE NORMALLY DOES NOT COVER FEES FOR LATE CANCELLATIONS, NO SHOWS OR TELEPHONE CONSULTATIONS.
 
Generally, identifying information, dates of service, type of service and diagnosis is required for insurance coverage. Some plans also require background information about you, more detail about your problems and diagnoses, and our treatment plan. Rarely, they may require that we send them your entire clinical record. Your insurance company will decide, based upon the information we send them, whether they will cover our services. If they approve further sessions, they might assign us a specific number and require us to work on your problem as intensely as possible with the focus of eliminating acute symptoms. We will work with you to accomplish the identified goals in a cost-effective manner.
Sometimes people are uncomfortable sharing personal information with their insurance company. Should you prefer that we not bill your insurance company, we will respect that.


Primary Insurance Company:
ID#:
Employer / Group Name:
Group#:
Subscriber is:Self  Spouse  Parent 
Name:
Date of Birth:
Phone#:
Address:
City: State: Zip:
Please sign to show that you have read and understand there may be limits to your insurance coverage. Your signature will authorize ABA2DAY Behavior Services, LLC to bill your insurance for services, our office to disclose requested information to your insurance company, and your insurance to reimburse us for those services.
Print Name:
Signature:
Date:
CLIENT CUSTODY INVOLVEMENT POLICY
 
Aba2day Behavior Services employees and independent contractors do not conduct custody evaluations, provide documentation to assist in custody hearings nor participate in custody hearings. Educational or behavioral testimonies for specific ABA services or school placement will be accepted or declined based on each individual case. Family or district will be charged a fee by ABA2DAY Behavior Services. For fees related to expert witnesses please contact aba2dayinfo@gmail.com for the specific terms and fee agreement.
 
BY SIGNING BELOW, I VERIFY THAT I HAVE READ AND UNDERSTAND ALL INFORMATION GIVEN TO ME IN THIS FORM.
 
Print Name:
 
Signature:
 
Date:

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