Page 1 of 14

Welcome!

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Welcome to {Company Name}

Welcome to the {Company Name}!

{Company Name} is pleased to have you join us. We ensure that we are a highly inclusive, culturally sensitive, culturally respectful, and culturally competent organization. We will make every effort to ensure you are treated with respect and dignity at all times, in consideration of the following (but not limited to): racial, ethnic or cultural customs, practices, and beliefs; sexual orientation; gender, gender identity, and gender expression; disability, and community differences.

Further, {Company Name} will take reasonable steps to ensure that those with Limited English Proficiency (LEP) have meaningful access and equal opportunity to participate in our services, activities, and programs.

1100 New Britain Ave, Suite 107
West Hartford, CT 06110
Phone Number: 860-233-3033
amy@puzzlellc.com
Fax Number: 858-924-0244
www.puzzlellc.com

*Parent/Caregiver's Name

*Signature

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CLEAR

I accept that this is the legal representation of my signature.

*Date Completed:

Page 2 of 14

Client Handbook Part 1

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CONFIDENTIALITY POLICY

{Company Name} provides direct services to clients and their families.

CONFIDENTIALITY

We hold information about the client and family in the upmost confidential regard. Records and information obtained from or pertaining to the client will be kept confidential and released only in accordance to stated regulations. Our team members receive training to act in accordance with the regulations of the Health Insurance Portability and Accountability Act (HIPAA). “The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that sets rules about who can look at and receive your health information. This law gives you rights over your health information and when it can be shared. It also requires your doctors, pharmacists and other health care providers, and your health plan to explain your rights and how your health information can be used or shared” (courtesy of U.S. Department of Health and Human Services Office of Civil Rights). To learn more, visit www.hhs.gov/ocr/privacy/.

There may be times when it is important for staff at {Company Name} to communicate with your child’s staff at school, service providers, or health providers. Communication between providers can help ensure consistency and continuity of services for your child. You will be asked to sign a release of information so any staff at {Company Name} may communicate with other providers.

Consequently, we are handling with health information on a daily basis. {Company Name} is bound by HIPAA regulations that require organizations to protect the sensitive health information of their clients. Protected Health Information (PHI) includes "any information, whether oral or recorded in any form or medium" that "relate(s) to the past, present, or future physical or mental health or condition 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 an individual." Therefore, to ensure the confidentiality of every client that we treat, we have developed certain standards of care that employees must be aware of and agree to.

Employees acknowledge the following policies about clients, employees will never disclose or discuss protected health information, client care, programming, client name, etc. with anyone who is not employed by {Company Name} . Employees will take every precaution to ensure that data sheets, log books, or other sensitive documents that could reveal a diagnosis is protected (e.g., in a locked filing cabinet and always on their person when not under lock and key); employees will never communicate or publish protected health information of clients including names and images in physical or electronic form without prior written consent of the client and {Company Name}

All records, including but not limited to medical and psychological reports, videotapes, DVDs, photographs, voice recordings, data and information related to the client ("Confidential Information") are the property of {Company Name}. Team members should not disclose any Confidential Information to any person or use any Confidential Information for the benefit of the team member or any other person, except with the prior written consent of the {Company Name}.

Due to the sensitive nature of information, it is imperative that {Company Name} keeps sensitive information confidential. Any information about your children or family will be shared on a "need to know" basis only. Thus, {Company Name} is very sensitive about discussing your child's developmental needs and your family information in public places. Your client information will not be left unattended at any time (i.e., session notes, data sheets, binders). All devices (i.e., phones, iPads, computers) have auto-lock and password enabled at all times. In the case that a device is missing or stolen the team member will notify the director immediately. {Company Name} has the capability of erasing all its electronic devices to avoid a breach of sensitive information. Your client information will not be shared on any forms of social media sites. Emails containing sensitive information sent outside of the {Company Name} network to authorized professionals will be password protected.

Please be prepared to share all previous or ongoing evaluation reports pertaining to the client to include medical information, psychological evaluations, and school reports. It is important for {Company Name} staff to be able to review the collective information gathered from other professionals and disciplines to provide the most comprehensive services possible. You will be asked to sign a Consent to Release Information form before an {Company Name} staff member may engage in any communication or discussion with another provider.

*Parent/Caregiver's Name

*Signature

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CLEAR

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*Date Completed:

Page 3 of 14

Client Handbook Part 2

Notice of Privacy Practices

This notice describes how medical/mental health information about you may be used or disclosed and how you can get access to this information. Please review it carefully.

{Company Name} must to maintain the privacy of your health information and to provide you with this notice. You will be asked to sign a Release of Information Form. Once you have signed the Release of Information Form, {Company Name} staff members may use or disclose your Protected Health Information (PHI) for purposes of diagnosis, treatment, obtaining payment, or to conduct healthcare operations. For example, to receive payment for our services, {Company Name} must provide information to the funding source being used.

Other permitted and required uses and disclosures that may be made without your consent, authorization, or opportunity to object:

Abuse or Neglect: If any {Company Name} member suspects abuse or neglect of a child and elder, he/she is mandated to make a report to the appropriate public authorities.

Danger: If an {Company Name} staff member suspects that you are in imminent danger of harming yourself or someone else, he/she is mandated to make a report to the person at risk to the public authorities.

Legal Proceedings: {Company Name} staff members may disclose PHI in response to a court order or subpoena or certain other legal proceedings.

You have the following rights regarding PHI A Piece of the Puzzle Behavioral Interventions LLC maintains about you.

Right to Inspect and Copy: You have the right to inspect and request copies of information that may be used to make decisions about your care. Usually, this includes demographic and billing records but does not include case notes. To inspect and receive copies of information, you must submit a request in writing. If you request a copy of the information, {Company Name} may charge a fee for the cost of copying, mailing, or other supplies associated with your request. {Company Name} must respond to your request within fifteen days of receipt.

Right to Amend: If you feel that PHI about you is incorrect or incomplete, you may ask A Piece of the Puzzle Behavioral Interventions LLC to amend the information. You have a right to request an amendment for as long as A Piece of the Puzzle Behavioral Interventions LLC keeps the information. Your request for amendment must be in writing and must provide a reason supporting yourrequest.

Right to an Accounting of Disclosures: You have the right to request an Accounting of Disclosures regarding information that {Company Name} staff members have made about you. You must submit your request in writing to the above address. Your request must state a period for the disclosures, which may not be longer than six years and may not include dates before July 1,2011.

Right to Request Restrictions on Uses and Disclosures: You may request that disclosure of confidential information be limited. If {Company Name} is unable to agree to that restriction, we can discuss other options, such as referral to another counselor.

Right to Limit Reception of Confidential Information: For example, you may request that A Piece of the Puzzle Behavioral Interventions LLC staff members only contact you at a certain telephone number or address. You do not have to give a reason for your request.

Right to a Paper Copy of this Notice of Privacy Practices: You have a right to a paper copy of this signed notice.

Other uses and disclosure of PHI and any disclosure of Case Notes will be made only with your written authorization. After such authorization is given, you may revoke that authorization at any time from future use. This notice may be amended as needed to comply with federal, state, and professional requirements.

Notice of Privacy Practices Receipt Form

,have read and received a copy of the Notice of Privacy Practices from the staff of {Company Name}.

*Parent/Caregiver's Name

*Signature

Please sign in the box below using your mouse, touch screen, or touchpad.

CLEAR

I accept that this is the legal representation of my signature.

*Date Completed:

Page 4 of 14

Client Handbook Part 3

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Mandated Reporter Disclosure

All behavioral staff members for the in-home program operated by {Company Name} are mandated reporters as deemed so by Company’s State: CT state rules, regulations, and laws. This is true of all social workers, teachers, etc., and should not restrict the work to be completed. This is a state law designed to protect children from injury and should not be viewed as means to harm parents and caretakers.

This form shall serve as a reminder to the family of this fact, and shall also provide insight into what this disclosure means. This disclosure shall serve as part of the client education regarding the program, and the client information packet.

As a mandated reporter, the Behavior Therapist for the {Company Name} program is required by law to report any and all allegations, reports, and suspicions of child abuse, neglect, and maltreatment to the appropriate identified governing body.

Child Protective Services is the governing body identified in the state of Georgia regarding cases of child abuse, neglect, and maltreatment, and the Behavior Therapist is required and shall, therefore, report the incidents mentioned above to the National Hotline for Child Protective Services.

Any report to Child Protective Services, where deemed necessary by them, shall constitute a separate case from the one managed by {Company Name} intensive in-home program. For this reason, it should be noted that the Behavior staff shall only participate in cases as required and requested by Child Protective Services. The intensive in-home program operated by {Company Name} shall play no part in decisions made by Child Protective Services and should be viewed as a separate organization from Child Protective Services.

The client shall sign a Mandated Reporter Disclosure Receipt Form that shall be kept in the client's file as evidence that the information mentioned above has been provided to the client and family.

Mandated Reporter Disclosure Receipt Form

I,have read and received a copy of the Mandated Reporter Disclosure Form policy from the Behavioral staff of the in-home behavior intervention program operated by the A Piece of the Puzzle Behavioral Interventions LLC agency.

Child’s Name:

*Parent/Guardian Name

*Parent/Guardian Signature

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CLEAR

I accept that this is the legal representation of my signature.

*Date Completed:

Page 5 of 14

Client Handbook Part 4

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Resolving Grievances

We encourage the client to discuss any matter of concern regarding the services delivered by {Company Name} staff with the BCBA assigned to the case for the purpose of resolving a concern.

Early and immediate resolution of concerns and conflicts is strongly encouraged, and a meeting may be scheduled with the client, staff member, BCBA, and the designated management staff to assist in reaching a satisfactory resolution.

If you feel like the issue/concern has not been resolved, please fill out a formal complaint.

Within two (2) business days of receipt of a written complaint (Via email or letter), the Director of Operations will respond.

In the event there is not a satisfactory resolution reached with the Director of Operations, the client may appeal the matter to the Director of Clinical Services.

Within five (5) business days of an appeal, the Director of Clinical Services will contact the Client with the final resolution. If the client is still not satisfied, they have the right to refuse services, contact their insurance company/case manager (if applicable), or contact local, state, or federal government agencies.

*Parent/Caregiver's Name

*Signature

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CLEAR

I accept that this is the legal representation of my signature.

*Date Completed:

Page 6 of 14

Client Handbook Part 5

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ABA Therapy Service Agreement

During the term of this agreement, {Company Name} will provide ABA Therapy services, and the parents/guardians will compensate {Company Name} a payment for the services as described below in the terms and conditions specified. I understand all the fees and conditions as stated above.

IF IT BECOMES NECESSARY FOR THIRD PARTY COLLECTION, I AGREE TO PAY FOR ALL COSTS AND EXPENSES INCLUDING REASONABLE ATTORNEY FEES.

Services

During the terms of this agreement {Company Name} shall provide the following services:

Behavioral treatment services, which may include, but are not limited to: direct one-on-one instruction, a continuation of assessments, and modification of programs (data review), completion of Functional Behavior Analysis (FBA) or Functional Behavior Analysis for problem behaviors, an update of Behavior Intervention Plan (BIP), and parent training.
Other professional services can be requested but are not included in this service agreement may include, but are not limited to:
- Program development
- Attendance to meetings or consultations with other professionals you have authorized
- Preparation of records or treatment summaries
- Time required to perform any other service which you may request

I agree to the terms of the above agreement:

*Parent/Caregiver's Name

*Signature

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CLEAR

I accept that this is the legal representation of my signature.

*Date Completed:

Page 7 of 14

Client Handbook Part 6

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Crisis Intervention

Severe aggressive behavior will be assessed by the {Company Name} staff including, at minimum, the executive director, supervisor, and therapist. The level of risk in the home will be assessed to determine if services can continue to be provided safely without the use of physical intervention. {Company Name} staff will block aggression and self- insurance behavior, but will not use physical restraint.

Please Initial Below

I prefer my child's therapist help assist my child when physical redirection is needed

(Please initial)

I prefer I only help assist my child when physical redirection is needed

(Please initial)

I prefer we both together assist my child physical when redirection is needed

(Please initial)

I have fully read, understand, and have inserted my initial next to my preference to the above in this.

Please select one

Child’s Name:

*Parent/Guardian's Name

*Parent/Guardian Signature

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CLEAR

I accept that this is the legal representation of my signature.

*Clinician Name

*Clinician Signature

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CLEAR

I accept that this is the legal representation of my signature.

*Date Completed:

Page 8 of 14

Client Contact Information

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*Mother's Name

*Mother's Cell Phone Number

*Mother's Work Phone Number

*Mother's Email Address

*Father's Name

*Father's Cell Phone Number

*Father's Work Phone Number

*Father's Email Address

*Home Phone Number

*Child's home address

Emergency Contact

*Name

*Relationship to child

*Cell Phone Number

*Work Phone Number

*Email Address

Page 9 of 14

Parent Questionnaire Part 1

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Please answer each question below. There are no right or wrong answers.

My child’s strengths

My child’s areas of need

Page 10 of 14

Parent Questionnaire Part 2

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*Some activities I like to do with my child are:

*I wish I could enjoy the following activities with my child but is not possible at the moment:

*Have you observed overall improvement in your child’s behavior and ability to learn new skills? Please explain

*In what areas/skills would you like parent training and support?

*Is there anything else that you would like to discuss? Please write any questions or concerns that you have regarding your child and ABA services.

Page 11 of 14

Medical Questionnaire Part 1

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*Child's Name

*Age

*Date Completed:

*Form completed by?

*Relationship to child

*Are you the legal guardian of this child and are you able to make medical decisions on his/her behalf?

*Notes:

Medical History:

*Please list your child's primary care physician name, contact number, address and email.:

*Does your child have any allergies?

*Please list below allergies:

*If life threatening please list below.

*Instructions for allergic reactions:

*Does your child have any dietary restrictions?

*Please list dietary restrictions

*Is your child being treated for any health problems?

*Please list health problems

*Other hospitalization (non-surgical)?

*Please list the reasons and date, starting with the most recent:

*Has your child every had surgery?

*Please list the reasons and date, starting with the most recent:

*Emergency Room Visits?

*Please list the reasons and date, starting with the most recent:

Birth History:

*Please describe birth history including any complications below.

*Birth Weight:

*Weeks Gestation:

Welcome!

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Welcome to {Company Name}

Client Handbook Part 1

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CONFIDENTIALITY POLICY

Client Handbook Part 2

Notice of Privacy Practices

Client Handbook Part 3

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Mandated Reporter Disclosure

Client Handbook Part 4

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Resolving Grievances

Client Handbook Part 5

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ABA Therapy Service Agreement

Client Handbook Part 6

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Crisis Intervention

Client Contact Information

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Emergency Contact

Parent Questionnaire Part 1

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My child’s strengths

My child’s areas of need

Parent Questionnaire Part 2

Medical Questionnaire Part 1

Medical Questionnaire Part 2

Medical Questionnaire Part 3

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Medical Questionnaire Part 4

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