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13327 Lorem Ipsum, USA
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Intake Form
CLIENT INTAKE FORM
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Thank you for interest in La Ruche. Please fill the client intake form to provide sufficient information concerning how we can best assess your needs and be of service. Once the forms are completed, we can better determine the path to beginning your child’s treatment and set up an initial meeting to review main proprieties for you and your family. We are very excited to begin this journey with you. Sincerely, Cheryl & Effie
Client Information:
Name
(Required)
First
Last
Date of Birth:
(Required)
MM slash DD slash YYYY
Age
(Required)
Gender
(Required)
Male
Female
Other
Race/Ethnicity
Main Language Home
Complications during birth
Yes
No
Details
Birth weight LBS/OZ
Diagnosis Information:
Does the learner have a diagnosis?
(Required)
Yes
No
On waiting list for evaluation?
(Required)
Yes
No
Has appointment with:
Appointment date
MM slash DD slash YYYY
Parent/Guardian Information:
Mother
First
Last
Father
First
Last
Guardian
First
Last
Mother's Email Address
Father's Email Address
Guardian Email Address
Mother Phone Number
Father Phone Number
Guardian Phone Number
Work # Phone Number
Home Information
Parents
(Required)
Single
married
Number Of Siblings
Sibling #1
Male
Female
Sibling #1 Age
Sibling #2
Male
Female
Sibling #2 Age
Sibling #3
Male
Female
Sibling #3 Age
Sibling #4
Male
Female
Sibling #4 Age
Sibling #5
Male
Female
Sibling #5 Age
Availability for ABA Appointments
Appointment Time
Morning
Afternoon
Appointment Day
M
T
W
TH
F
Prefered Times of Day
Prefered Time Of day1
Hours
:
Minutes
AM
PM
AM/PM
Prefered Time Of day1
Hours
:
Minutes
AM
PM
AM/PM
Prefered Time Of day3
Hours
:
Minutes
AM
PM
AM/PM
Psychological History
Family history
Siblings/distant family members with diagnoses?...
Developmental History Please Indicate Age Of:
Rolling over
Sat up unsupported
Stood
Crawled
Walked unassisted
Said first word intelligible to strangers
Said 2-3 word phrases
Used sentences
Toilet trained (day)
Dry through night
Dressed self
Other difficulties:
Problems making/keeping friends
Problems getting to sleep
Problems sleeping through the night
Trouble waking up (Fatigue/tired)
Nightmares
Bed wetting/soiling
Problems controlling temper
Problems with authority
Anxiety
Unmotivated
Stress from conflict between parents
Legal situation
History of abuse
History of drug use
Difficulty with school concentration
New addition to the family
Behavior towards pets
Sadness or depression
Other Medical History
Allergies
Illnesses
Ear Infections
Surgeries
Cancer
Diabetes
Asthma
Other (Please Specify):
Requirements to receive services:
Intake form and Intake meeting
Assessments:
Verbal Behavior Milestones assessment and placement program (VB-MAPP)
Functional Behavior Assessment (FBA)
Assessment of Basic Language and Living skills (ABLLS-R)
Assessment of Functional Living Skills (AFLS) etc.
Parent Meeting: Goals review, development of treatment plan & scheduling
Monthly review of progress
ABA Therapy:
La Ruche utilizes the principles of Applied Behavior Analysis to develop individualized treatment plans that target language communication, cognitive skills, self-help skills, imitation, social skills and pre-academic skills which are based on the learner’s strengths, and focuses on decreasing skill deficits. Data is collected on the environmental variables that maintain a learners behavior and behavior support plans may be implemented. Data is continuously collected and analyzed to determine the effectiveness of the treatment in place. The goal of the program is to utilize behavioral contingencies to help the child replace any undesirable behaviors and improve overall quality of life in the short and long term.
Prompting
Prompting is a way of assisting the client to accurately complete a task. One of the best prompting hierarchies to use with clients is most to least prompting. You want to use the most effective prompt for the learner to complete the task and prevent any errors from developing within the response chain. As the client is learning the responses, prompts are faded until the client can complete the response independently. Most to least prompting hierarchy may look like the following: Full physical prompting, partial physical prompting, gestural prompt, independent. This depends on the skill that the client is learning. Applied behavior analysis (ABA) therapists utilize prompts during sessions to support their client in performing a specific task. The term ‘prompting’ means to provide cues or assistance to help encourage the use of a skill. Prompts help children with autism perform a task until it is learned in the most natural way. The ultimate goal of using a prompt is to allow an individual to perform skills independently and in the correct situation without further cues.
Types of prompt levels are:
Full physical prompts:
this is when the instructor fully prompts the complete action for the client. These may include hand or physical direction: guidance to an activity, touching mouth to shape a vocal response, hand on hand prompts to touch an item in an array.
Partial physical prompts:
this is when the instructor only needs to prompt part of the action for the client
Gestural prompts:
this is when the instructor can gesture or point towards what the client needs to do
Partial physical prompts:
this is when the instructor only needs to prompt part of the action for the client
Model prompts:
this is when the instructor demonstrates the skill/action for the client
Full verbal prompts:
this is when the instructor states the full word/sentence that the client needs to emit or gives an instruction
Partial verbal prompts:
this is when the instructor is able to fade to part of the word that the client needs to emit (e.g. "Ch" instead of "Chips")
Changes/Termination of Treatment:
As the consumer, you reserve the right to ask for treatment changes or withdraw from services. This agreement involves an understanding from you the consumer to follow through with treatment plan suggestions to maximize your child’s treatment progress. Failure to adhere to the treatment recommendations may contribute to potential discharge and/or transition of services. Furthermore, if disagreement regarding behavior change procedures and/or treatment plan goals occur, you the consumer will work with the supervisor to alter said goals. Justification and clarification for behavior change procedures will be thoroughly explained so you the consumer will understand reasoning for implementation. Upon agreement of plan/goals, failure to adhere to the plan will result in termination of treatment. Discharge may also occur if La Ruche is unable to meet your scheduling and/or treatment needs due to staff availability.
Reasons for discharge/termination:
Caregiver/client request
Inadequate progress despite treatment fidelity over a substantial period of time
Complete outcome of service: Client's referred excesses and deficits have been addressed and remediated. All problem behaviors identified at entry of service have been addressed and are exhibited within typical ranges. This may also include age-appropriate ranges of development on standardized testing in the areas of diagnostic criteria, cognition, language (basic speech and language as well as a pragmatic language), social problem solving, executive functioning, and adaptive skill functioning.
Failure to pay bill according to agreement
Inappropriate behavior or language towards staff
Cancellations, Therapist Information and Vacation
Cancellations:
All appointments except for rare emergencies, will be kept for your child at the time scheduled. We understand that circumstances such as an illness or family emergency may arise which necessitates the occasional cancellation of appointments. In these cases, in order to avoid any misunderstanding, we ask that you speak to our scheduling manager and give as much notice as possible to cancel or reschedule. This will allow us to offer your time to another person. You may be charged the standard hourly rate ($60) for appointments missed or cancelled with less than 24 hours advance notice. Please note that you remain responsible for these charges. Should the therapist cancel sessions, they will reschedule within the next possible convenience determined by the parent and therapist.
Therapist Information:
An Intervention therapist following a plan outlined by the Board-certified Behavior Analyst (BCBA) will provide direct 1:1 therapy in the designated setting (daycare, center). Each Intervention Therapist has experience providing services to children with Autism and has completed our 40-hour ABA training.
Vacation:
We request that families give us at least two week’s notice prior to vacation or any significant changes in their ABA scheduled sessions to facilitate consistency in service delivery. Intervention therapists will deliver at least two weeks notice prior to the cessation of their services, or in the case where they take vacation.
Picking up on time:
The universal standard for therapy is that the last 15 minutes of each session is devoted to data collection, note writing, material preparation/organization for the following session and discussion of the session with the parent. The parent should arrive at least 15 minutes early to pick up their child. Should additional time be needed to discuss components of the learner’s intervention program, parents are invited to set up an additional meeting outside of the programs monthly meeting which is included in the intervention program at the regular consultation fee of 150$ per hour.
Confidentiality, Records, and Release of Information Services are best provided in an atmosphere of trust. Because trust is so important, all services are confidential except to the extent that you provide us with written authorization to release specified information to specific individuals or agencies. To Protect the Client or Others from Harm If we have reason to suspect that a client or other minor is being abused, we are required to report this (and any additional information upon request) to the appropriate agency. If we believe that a client is threatening serious harm to him/herself or others, we are required to take protective actions, which could include notifying the police, an intended victim, a minor’s parents, or others who could provide protection, or seeking appropriate hospitalization.
Professional Consultations
Behavior Analysts routinely consult about cases with other professionals. In so doing, we make every effort to avoid revealing the identity of our clients, and any consulting professionals are also required to refrain from disclosing any information we reveal. We will inform clients of these consultations. If you want us to talk with or release specific information to other professionals with whom you are working, you will need to sign an authorization specifying what information can be released and with whom it can be shared.
At La Ruche, we strive for excellence in our ABA program to achieve desired outcomes and in order to achieve that goal we ensure that the family is involved in the process. Caregivers must carry over therapy so that programs are implemented and data is recorded for specific programs outlined the client’s treatment plan. If the Client/Family refuses involvement in the treatment plan, as a last resort services may be suspended or terminated based on the severity of the lack of involvement. Without the client/family involvement, out treatment plans will not be as effective as possible and our main goal is for the client to reach their full potential. After one month of pairing and starting the learner’s goal, parents will be requested to join the session at least one time per month, or based on the goals for that family/client.
Permission to Videotape, Audiotape or Photograph
I give consent for La Ruche to videotape, audiotape and/or photograph my child and/or myself during the time my child is enrolled in services. I understand these videotapes, audiotapes and/photographs may be used in educational training presentations. I understand these videotapes, audiotapes/photographs will not be used outside the company and will be kept confidential. I understand that the tapes will be used for the purposes of developing more effective educational and therapeutic plans for my child and also for the purpose of education and training for Parapluie Bleu and their families.
Child’s name
Date of birth
MM slash DD slash YYYY
Print name (parent/guardian)
Date
MM slash DD slash YYYY
Signature (parent/guardian)
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Child’s name:
Date of birth
MM slash DD slash YYYY
Print name (parent/guardian)
Date
MM slash DD slash YYYY
Signature (parent/guardian)
Reset signature
Signature locked. Reset to sign again
Discipline and Home Life:
Parents may use a wide range of discipline strategies with their children. Listed below are several examples. Please rate how likely you are to use each of the strategies listed by checking the appropriate box.
Let the situation go
Very Likely
Likely
Sometimes
Never use
Take away privilege
Very Likely
Likely
Sometimes
Never use
Assign additional chore
Very Likely
Likely
Sometimes
Never use
Take away toy
Very Likely
Likely
Sometimes
Never use
Ignore
Very Likely
Likely
Sometimes
Never use
Send to room
Very Likely
Likely
Sometimes
Never use
Talk/explain to calm
Very Likely
Likely
Sometimes
Never use
Time out
Very Likely
Likely
Sometimes
Never use
Yell/argue/raise voice
Very Likely
Likely
Sometimes
Never use
Other Strategies:
Routines/Transitions:
Does your child have difficulty with ?
Trouble with sudden change
Yes
No
Difficulty with changes they are warned about
Yes
No
Fears (animals, sounds, places etc.)
Yes
No
Does your child engage in Tantrums/Aggression/Self-Injury: Describe behavior:
Is this behavior disruptive enough that you feel it needs to be addressed?
Yes
No
Language
Does your child appear to understand language (even if he can’t talk)? For example, “let’s go shopping”, (the child will go to the door and wait for you)
Not at all
A Little
This is a strength
Can understand more complex sentences (“Go get your red shoes,” or “Give me the one that is not wet”)
Yes
No
Can he/she follow directions?
Yes
No
Expressive Communication:
Does your child use language?
To request needs/wants:
Never
Somtime
Always
To greet others
Never
Somtime
Always
Answer simple questions (ex. what’s your name?)
Never
Somtime
Always
Social/Play:
Does your child play?
By himself?
Never
Somtime
Always
Next to but not with others?
Never
Somtime
Always
With other children?
Never
Somtime
Always
Sometimes when teaching our students appropriate replacement behaviors, students may become upset or cry. When this happens, we are very adept at working through these instances with favorable outcomes. We want to understand how you feel about this when it happens.
(Please note that all behavior support plans are discussed with parents and strategies for responding are explained and approved.)
I am comfortable with letting my child cry and letting providers handle the situation
I am NOT comfortable with letting my child cry and letting providers handle the situation
I am unsure at this time
ABA Therapy Contract
La Ruche is offering ABA therapy sessions (Applied Behavioral Analysis) at an hourly rate of $60 for Per Hour of ABA therapy for the following amount of hours:
located at (location):
A Verbal Behavior Milestones Assessment and Placement Program (VB-Mapp) will be completed during the first few sessions with your child. Assessments may take between 2 to 10 hours to complete. Following the assessment, the parent/guardian will attend a meeting with our BCBA to discuss recommendations and priorities. The intervention plan will then be put into place.
The cost of 60$ per hour includes the following:
Administrative services:
Opening a file
Billing
Record keeping/updates
Therapy hours
2 hours of monthly in-therapy supervision by BCBA or Qualified Supervisors
A monthly meeting to discuss the child’s progress
All photocopies, program set up, binder (physical/electronic), and toys
Your signature below indicates you have received and read the information in this document. Consent by all parents/legal guardians is required for the implementation of ABA services. By signing this agreement, you consent to receive ABA treatment in the manner in which it’s described above.
These policies have been fully explained to me and I have had all questions answered in relation to the information provided in this document. I also understand I have the right to withdraw my consent at any time.
I fully and freely give my consent for services to be implemented as proposed.
Printed Name
Date
MM slash DD slash YYYY
Signature of Parent/Guardian
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Date
MM slash DD slash YYYY
La Ruche Representative
Reset signature
Signature locked. Reset to sign again
Date
MM slash DD slash YYYY
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Home
About Us
Services
Workshop
Classes
Event Nights
Special Events
Contact Us
Visit Us Daily from 8.00 AM to 6.00 PM
13327 Lorem Ipsum, USA
[email protected]
Request a Free Consultation
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EN
FR
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