Client Intake

Date(Required)

Child's Info

Child's Name(Required)

Child's Date of Birth(Required)

Gender(Required)

Male

Female

Primary Health Insurance Info

Insurance Company(Required)

Member ID(Required)

Group #(Required)

Policyholder's Name(Required)

Usually a parent.

Gender(Required)

Male

Female

Policyholder's Date of Birth(Required)

Policyholder's Social Security Number(Required)

Policyholder's Address(Required)

Street Address Address Line 2 City State ZIP Code

Secondary Health Insurance Info

Insurance Company

Member ID

Group #

Policyholder's Name

Usually a parent.

Gender

Male

Female

Policyholder's Date of Birth

Policyholder's Social Security Number

Policyholder's Address

Street Address Address Line 2 City State ZIP Code

Parent Info

Custodial Parent(Required)

Both: Parents are married

Child live with father

Child lives with mother

Custodial Parent's Name(Required)

Custodial Parent's Email(Required)

Custodial Parent's Phone(Required)

Parent #2 Name

Parent #2 Email

Parent #2 Phone

Emergency Contact

Other than parents.

Emergency Contact Name(Required)

Emergency Phone Number(Required)

Desired Services

ABA Therapy(Required)

In-Center ABA

In-Home ABA

In-School Shadowing ABA

Speech Therapy(Required)

Yes

Occupational Therapy(Required)

Yes

HIPAA Agreement Form

PRIVACY POLICY

Carolina Behavioral Innovations is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI).
Carolina Behavioral Innovations will not use or disclose your PHI for marketing or fundraising purposes; Carolina Behavioral Innovations will not sell your PHI to anyone for any reason.
Carolina Behavioral Innovations will only use your PHI in an appropriate manner for treatment.
Carolina Behavioral Innovations will only disclose PHI to the child’s legal guardian. A legal guardian must give written authorization to allow us to share PHI with others.

RIGHTS

You have the right to access your PHI at anytime. Carolina Behavioral Innovations does not charge fees to access your records.
You have the right to know who had access to your PHI within the last 6 years.
You have the right to limit our access to your health records.
You have the right to revoke access to your PHI that was previously given to us at any time.
Carolina Behavioral Innovations will notify you immediately if we become aware that an unauthorized person accessed your PHI.
You have the right to complain to the US Department of Health and Human Services if you feel that your rights have been violated.

EXCEPTIONS

Carolina Behavioral Innovations may disclose your PHI without your written permission when required By Law. When disclosure is (a) required by federal, state, or local law; judicial, board, or administrative proceedings; or, law enforcement; (b) compelled by a party to a proceeding before a court, arbitration panel or an administrative agency pursuant to its lawful authority; (c) required by a search warrant lawfully issued to a governmental law enforcement agency; or (d) compelled by the patient or the patient’s representative pursuant to state or federal statutes or regulations, such as the Privacy Rule that requires this Notice.
Carolina Behavioral Innovations may disclose your PHI without your written permission for health oversight activities authorized by law including, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
Carolina Behavioral Innovations may disclose your PHI without your written permission to avoid harm. When disclosure: (a) to law enforcement personnel or persons may be able to prevent or mitigate a serious threat to the health or safety of a person or the public; (b) is compelled or permitted by the fact that the Client is in such mental or emotional condition as to be dangerous to him or herself or the person or property of others, and if AST determines that disclosure is necessary to prevent the threatened danger; (c) is mandated by state child abuse and neglect reporting laws (for example, if we have a reasonable suspicion of child abuse or neglect); (d) is mandated by state elder/dependent abuse reporting law (for example, if we have a reasonable suspicion of elder abuse or dependent adult abuse); and (e) if disclosure is compelled or permitted by the fact that you or your child tells us of a serious/imminent threat of physical violence against a reasonably identifiable victim or victims.
Carolina Behavioral Innovations may disclose your PHI without your written permission to company attorneys, accountants, consultants, and others to make sure that Carolina Behavioral Innovations is in compliance with applicable laws.
Carolina Behavioral Innovations may disclose your PHI without your written permission to your health insurance company to obtain benefit information, payment for treatment and services provided.
Carolina Behavioral Innovations may disclose your PHI without your written permission in the event of an emergency situation (such as a hospital visit).

SURVEILLANCE SYSTEM

Inside our center, there are video cameras that record video/audio.
Carolina Behavioral Innovations is the owner of all video/audio. No one (not even the parents) is allowed to possess pictures/video/audio from our surveillance footage (unless subpoenaed by a court).
This video/audio may be used by Carolina Behavioral Innovations for parent training or staff training.

Print Name(Required)

Date(Required)

Signature(Required)

Payment Agreement

Print Child's Name(Required)

AUTHORIZATION:

I authorize Carolina Behavioral Innovations to make medical reimbursement claims with my health insurance policy for services provided to my child.
Any pre-authorization obtained by Carolina Behavioral Innovations is not a guarantee of payment by my insurance.
I understand and accept that I am ultimately financially responsible for all amounts not covered by my health insurance, including (but not limited to) co-payments, deductible, co-insurance, and other fees.
Discounts for copays and deductible amounts are not allowed by law.
I understand and agree that I am responsible for the payment of all charges incurred regardless of any insurance coverage or other plans available to me.
I understand that Carolina Behavioral Innovations will bill me monthly for balances left unpaid by my health insurance. Invoices must be paid within 15 days of the date on the invoice.
If any of my invoices remain unpaid for over 90 days, my child’s services may be terminated.

ADDITIONAL FEES:

Field trip fees/camp fees
Replacement fees for Carolina Behavioral Innovations electronics when damaged by your child
Any and all collections costs and/or attorney’s fees if any delinquent balance is placed with an agency or attorney for collection, suit, or legal action.

INVOICE DISPUTES:

If I believe there is an error on my invoice, I must contact the billing department within 90 days of receipt of the relevant invoice in order to allow review and consideration.
Inquiries/Disputes regarding invoices over 90 days old will be deemed untimely and payment will be not be refunded.

Parent's Name(Required)

Parent's Social Security Number(Required)

Date(Required)

Parent's Birthday(Required)

Signature(Required)

Informed Consent For Services

Print Child's Name(Required)

Parent's Name(Required)

I hereby voluntarily apply for and consent to behavioral services by the staff of Carolina Behavioral Innovations. This consent applies to myself and the child named above.

I understand that parental involvement and trainings are required. I understand that Carolina Behavioral Innovations encourages both parents to attend the required meetings.

I understand that my child’s attendance is essential to the program and must be maintained at a level of 85% of scheduled sessions each month, and over the duration of enrollment.

I give permission to Carolina Behavioral Innovations to capture images/audio of my child while in the center. I also give permission to Carolina Behavioral Innovations to display these images/audio in the parent viewing room. I understand that other clients/parents/visitors may see these images/audio from the display in the parent viewing room.

I understand that I may ask for a referral to another professional if I am not satisfied with the progress of my treatment.

I understand that I have the right to refuse services at any time. I understand and agree that my continued participation implies voluntary informed consent. I also understand that Carolina Behavioral Innovations has the right to refuse services at any time.

Date(Required)

Custodial Parent's Signature(Required)

Informed Consent For Telemedicine Services

Print Child's Name(Required)

Parent's Name(Required)

Health care services are available by two-way interactive video communications and/or by the electronic transmission of information. Referred to as “telemedicine” or “telehealth,”, this means that I may be evaluated and treated by a health care provider or specialist from a different location.

Since this is different than the type of consultation with which I am familiar, I understand and agree to the following:

The consulting health care provider or specialist will be at a different location from me.
I will be informed if any additional personnel are to be present other than myself, individuals accompanying me, the consultant and presenting practitioner. I will give my verbal permission prior to additional personnel being present.
Video recordings may be taken of the telehealth consultation. Video recordings and other data, including documents, images, and photos may be kept, viewed, and used for purposes including teaching, training, technical, scientific, research, or administrative purposes.
The health care provider will keep a record of the consultation in my medical record.

Noting all the above, I understand that my participation in the process described (called “telemedicine” or “telehealth”) is voluntary and constitutes a waiver of the usual right to physician-patient privacy and may possibly increase the risk of disclosure of my medical data. I further understand that I have the right to:

Refuse the telehealth consultation, or stop participation in the telehealth consultation at any time.
Limit any physical examination proposed during the telehealth consultation.
Request that the presenting practitioner refrain from transmitting my information if I make the request before the information is transmitted.
Request that nonmedical personnel leave the room(s) at any time.
Request that all personnel leave the room(s) to allow a private consultation with the off-site specialist(s).

I acknowledge that the health care providers involved have explained the consultations in a satisfactory manner and that all questions that I have asked about the consultations have been answered in a manner satisfactory to me or to my representative. Understanding the above, I consent to the telehealth process described above.

Date(Required)

Custodial Parent's Signature(Required)

Security System Waiver

Print Child's Name(Required)

Parent's Name(Required)

I forever release and hold Carolina Behavioral Innovations harmless from any and all liability arising out of the use of the images/audio for training purposes, and waive any and all claims and causes of action relating to use of the images/audio, including without limitation, claims for invasion of privacy rights or publicity.

I agree to the following:(Required)

I grant Carolina Behavioral Innovations non-revocable permission to capture and store my child’s image and audio in video surveillance, moon pictures, and recordings while in the Carolina Behavioral Innovations center. I acknowledge that Carolina Behavioral Innovations will own such images/audio and further grant Carolina Behavioral Innovations permission to store and use these images/audio. I further waive any right to inspect or approve the use of the image/audio by Carolina Behavioral Innovations prior to its use.

Carolina Behavioral Innovations policy does not allow parents to take pictures/videos/audio while inside the building. Carolina Behavioral Innovations policy does not allow anyone to possess any pictures/videos/audio from our surveillance unless mandated by court order.

Inside our center, there are video cameras that record video/audio. When clients/parents/visitors come into the center, it is possible that they see other clients or overhear their ongoing treatment. By signing this agreement, you agree to keep confidential all information obtained by your presence concerning other clients.

Carolina Behavioral Innovations uses video/audio surveillance at every center.

Images may be used for marketing, advertising, or any public manner. These images/audio may be used for employee or parent training purposes.

Date(Required)

Custodial Parent's Signature(Required)

Release of Liability

Print Child's Name(Required)

Parent's Name(Required)

This Voluntary Waiver and Release Agreement (“Release”) is hereby executed by the undersigned parent, on his or her behalf and on behalf of the Child identified above, and each of their respective heirs, agents, executors, representatives, successors and assigns (collectively “Releasees”) in favor of and for the benefit of Carolina Behavioral Innovations, as well as the employees, owners, agents, shareholders, members, contractors, parent companies, subsidiaries and affiliates of each of them (collectively “Carolina Behavioral Innovations”). Releasees will attend certain behavioral training administered by Carolina Behavioral Innovations at the Carolina Behavioral Innovations clinic and/or in Releasees’ home (the “Services”). As a condition of receiving the Services, and prior to receiving any such Services, Releasees must execute this Voluntary Waiver and Release.

Releasees hereby assume all risk of accidents, personal injury, death and property loss and/or damage sustained or incurred by Releasees in connection with the Services, including, where permitted under applicable law, those caused as a result of negligence on the part of Releasees or actions of others present at the Carolina Behavioral Innovations clinic. Releasees acknowledge that it is their sole responsibility to evaluate carefully the risks inherent in visiting the Businesses’ location and receiving the Services, and that Releasees have fully considered those risks, including, without limitation, dangers posed by the negligence or other conduct of Releasees or others present at the Businesses’ location.
Releasees agree to and hereby do release, discharge, waive, indemnify and hold harmless Carolina Behavioral Innovations from and against all liabilities, actions, causes of actions, suits, damages, losses, judgments, claims and demands whatsoever, in law or in equity, including legal fees and costs, which Releasees may now or hereafter have against any Carolina Behavioral Innovations arising out of or in any way related to Releasees’ presence at Carolina Behavioral Innovations clinic or the Services, including, where permitted by applicable law, those caused by the negligence of Carolina Behavioral Innovations, or the negligence and/or conduct of others present at the Carolina Behavioral Innovations clinic, and including but not limited to claims for personal injury, death or property damage.
Releasees covenant and agree not to institute or bring any suit or action at law, or otherwise, against Carolina Behavioral Innovations, or in any way aid in the institution or prosecution of any claim, demand, action or cause of action for damages, costs, loss of services, expenses or compensation against Carolina Behavioral Innovations for or on account of any damage, loss or injury to Releasees and/or Releasees’; person or property, or both, resulting from or related to the Releasees’ presence at the Carolina Behavioral Innovations clinic or the Services.
Releasees acknowledge and understand that the Business and all other Carolina Behavioral Innovations franchisees are independently owned and operated business and are not owned by Carolina Behavioral Innovations. Releasees agree that if any portion of this Release is held invalid, the remaining portions and/or provisions shall be binding and continue in full force and effect.

I agree to the following:(Required)

I give my child permission to play on the playground/trampoline/monkey bars with the enclosed safety net while at Carolina Behavioral Innovations, with the understanding that there will be an adult present while he/she is doing so. I acknowledge that use of a trampoline can be dangerous and may result in serious injury or death if policies are not followed.

Occasionally, Clients may bring personally owned property (such as communication boards, iPads/tablets, iPods, specialized games, blankets, toys, etc.) into the center. I understand that Carolina Behavioral Innovations is not responsible for any damage/loss/theft to my property.

I hereby release Carolina Behavioral Innovations from any liability/claims/demands related to any loss/damage/injury to any of my personally owned property that my child may cause during in-home therapy sessions.

Releasees certify that Releasees have read this Release, fully understand it, and are not relying on any statements or representations made by Carolina Behavioral Innovations. Parents execute this Release knowingly and voluntarily.

Date(Required)

Custodial Parent's Signature(Required)

Health Information Disclosure

Print Child's Name(Required)

Child's Birthday(Required)

Confidentiality is a top priority at Carolina Behavioral Innovations. Therefore, it is important that you provide us with the following information to ensure there is no violation of your privacy. For more information on privacy laws, please read Privacy Act of 1974 (Public Law 93-579)

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

If I fail to specify an expiration date, event or condition, this authorization will not expire until treatment is terminated.

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules.

Doctor's Name(Required)

Doctor's Fax(Required)

Authorization Start Date(Required)

Authorization Expiration

(if applicable)

I hereby give permission for Carolina Behavioral Innovations permission to receive and share my child’s health information with all those listed above. I understand that if the status of any of the above information changes, it will be my responsibility to inform the staff at Carolina Behavioral Innovations.

Date(Required)

Parent's Name(Required)

Parent's Signature(Required)

Parent Handbook Agreement

Print Child's Name(Required)

Parent's Name(Required)

Click here to read the parent handbook

Date(Required)

Parent's Signature(Required)

Authorization for Parent Pickup

Print Child's Name(Required)

Child's Birthday(Required)

Custodial Parent's Name(Required)

Carolina Behavioral Innovations only allows a biological parent to pick up their child from our center (unless a court order states otherwise), regardless of who dropped the child off or their relation to the child.

In an effort to protect our clients, Carolina Behavioral Innovations asks that you let us know, in advance, who has your permission, other than you, to pick up your child from our center. You may pre-authorize individuals by listing them below. Please let these individuals know that they may be asked to show photo identification if a staff member is unfamiliar with them.

The following adults are allowed to pick up my child from Carolina Behavioral Innovations:

Name

Phone

Name

Phone

Name

Phone

I hereby give permission for my child to be picked up from the listed individuals. I understand that my child will not be released to any individual that is not listed on this form.

Date(Required)

Custodial Parent's Signature(Required)

Parent #2 Signature

Trauma Screening

Print Child's Name(Required)

Child's Birthday(Required)

Carolina Behavioral Innovations desires to provide trauma-informed care for every child. We understand that every child’s past experiences will impact their current behavior. Without understanding their trauma history, we are at risk of unknowingly triggering previous trauma reactions. We understand that these situations are difficult for parents to discuss, so we will always do our best to respect your boundaries. We do ask that you be as open as possible in this form so that we can properly interact with your child and respect his/her past experiences.

Mark YES if it happened to your child to the best of your knowledge. Mark NO if it didn’t happen to your child.

Serious natural disaster like a flood, tornado, hurricane, earthquake, or fire(Required)

Yes

Serious accident or injury like a car/bike crash, dog bite, or sports injury.(Required)

Yes

Threatened, hit or hurt badly within the family.(Required)

Yes

Threatened, hit or hurt badly in school or the community.(Required)

Yes

Attacked, stabbed, shot at or robbed by threat.(Required)

Yes

Seeing someone in the family threatened, hit or hurt badly.(Required)

Yes

Someone doing sexual things to the child or making the child do sexual things to them when he/she couldn’t say no. Or when the child was forced or pressured.(Required)

Yes

Online or in social media, someone asking or pressuring the child to do something sexual. Like take or send pictures.(Required)

Yes

Someone bullying the child in person. Saying very mean things that scare him/her.(Required)

Yes

Someone bullying the child online. Saying very mean things that scare him/her.(Required)

Yes

Someone close to the child dying suddenly or violently.(Required)

Yes

Stressful or scary medical procedure.(Required)

Yes

Being around war.(Required)

Yes

Been kicked out of a school or daycare due to autism-related challenges or challenging behavior.(Required)

Yes

Attended a clinic or school that used frequent punishment procedures with your child for their challenging behaviors(Required)

Yes

Attended a clinic or school in which they were frequently placed into a restraint in response to their challenging behaviors(Required)

Yes

History of neglect (e.g. not being fed, being le alone for periods of me, etc)(Required)

Yes

Has been adopted(Required)

Yes

Has been in the foster care system(Required)

Yes

Was alive when parents went through separation or divorce(Required)

Yes

How often does the following happen?

Upsetting thoughts or images about a stressful event. Or re-enacting a stressful event in play.(Required)

Never

Once in a while

Half of the time

Almost always

Bad dreams related to a stressful event(Required)

Never

Once in a while

Half of the time

Almost always

Acting, playing or feeling as if a stressful event is happening right now.(Required)

Never

Once in a while

Half of the time

Almost always

Feeling very emotionally upset when reminded of a stressful event.(Required)

Never

Once in a while

Half of the time

Almost always

Strong physical reactions when reminded of a stressful event (sweating, heart beating fast).(Required)

Never

Once in a while

Half of the time

Almost always

Trying not to remember, talk about or have feelings about a stressful event.(Required)

Never

Once in a while

Half of the time

Almost always

Avoiding activities, people, places or things that are reminders of a stressful event(Required)

Never

Once in a while

Half of the time

Almost always

Increase in negative emotional states (afraid, angry, guilty, ashamed, confusion).(Required)

Never

Once in a while

Half of the time

Almost always

Losing interest in activities s/he enjoyed before a stressful event. Including not playing as much.(Required)

Never

Once in a while

Half of the time

Almost always

Acting socially withdrawn.(Required)

Never

Once in a while

Half of the time

Almost always

Reduction in showing positive feelings (being happy, having loving feelings).(Required)

Never

Once in a while

Half of the time

Almost always

Being irritable. Or having angry outbursts without a good reason and taking it out on other people or things.(Required)

Never

Once in a while

Half of the time

Almost always

Being overly alert or on guard.(Required)

Never

Once in a while

Half of the time

Almost always

Being jumpy or easily startled(Required)

Never

Once in a while

Half of the time

Almost always

Problems with concentration.(Required)

Never

Once in a while

Half of the time

Almost always

Trouble falling or staying asleep.(Required)

Never

Once in a while

Half of the time

Almost always

Email/Text Messaging Consent Form

Printed Consumer's Name:(Required)

Preferred Phone Number for Texting(Required)

In order to communicate with you by email, we need to be sure you are aware of the privacy issues that could arise when we communicate this way, and to document that you are aware of these issues and agree to them. If you want to communicate with your care provider through email or text messaging, please read and sign the form below.

Potential Risks of Using Text Messaging:
Carolina Behavioral Innovations, LLC may offer clients the ability to stay in touch via text messaging if the client chooses to do so. In the case of children under 18 years old, the parent or legal guardian must approve of email/text communication and sign this consent. Text messaging has a number of risks one should consider before making a final decision about its use. These include, but are not limited to, the following:

Text messages may not be received
Text messages can be circulated, forwarded or stored in electronic files
Text messages can be immediately sent worldwide and received by many intended and unintended recipients
Senders can easily misaddress a text message
Text messaging is easier to falsify than handwritten or signed forms
Backup copies may exist even after sender and/or recipient has deleted their copies
Text messages can be intercepted, altered, forwarded or used without ones knowledge or permission
Text messages can be used as evidence in court
Text messages can be lost in transmission

Potential Risks of Using Email:
Carolina Behavioral Innovations, LLC may offer clients the ability to stay in touch via email if the client chooses to do so. In the case of children under 18 years old, the parent or legal guardian must approve of email/text communication and sign this consent. Emailing has a number of risks that consumers should consider before using email. These include, but are not limited to, the following:

Email messages may not be received.
Email can be circulated, forwarded and stored in numerous paper and electronic files, in intended and unintended ways
Senders can easily misaddress an email message
Email messages can be immediately broadcast worldwide and received by many intended and unintended recipients
Email can be easier to falsify than handwritten or signed documents
Back-up copies of email may exist even after the sender or the recipient has deleted his or her copy
Email can be used as evidence in court
Email can be intercepted, altered, forwarded or used without authorization or detection
Email messages can be lost in transmission

Consumer Acknowledgment and Agreement
I acknowledge that I have read and fully understand this consent form. I understand the risks associated with email and/or text communication and consent to the conditions herein. Any questions I may have had were answered.

Conditions for the Use of Text Messaging and/or Email:
CBI will use reasonable methods to protect the security and confidentiality of email information sent and received. However, because of the risks listed above, CBI cannot guarantee the security and confidentiality of text or email communication, and is not responsible for improper disclosure of confidential information that is not caused by CBI’s intentional misconduct. Consent to the use of texting or email includes agreement with the following terms:

Email and/or text message correspondence must be specifically requested and initiated by the consumer or the minor consumer’s parent/guardian.
Your care provider shall not email or text any Protected Health Information unless you specifically request him/her to do so.
Any email that you send that discusses your diagnosis or treatment constitutes informed consent to the information being transmitted.
Emails and/or text messages containing clinical content will become a part of your medical record.
Although CBI staff will endeavor to read and respond promptly to an email or text message, CBI cannot guarantee that any particular text or email will be read and responded to within any particular period of time. Thus, you should not use text messaging or email for medical emergencies or other time-sensitive matters.
You are responsible for informing the provider of any types of information that you do not want sent by text message and/or email.
Your email/text will not be forwarded to a third party without your expressed permission, (or as required by law) unless you have already signed a release for CBI to communicate with a third party.
You may withdraw consent to communicate by text or email via written communication to the provider at any time.
If a life-threatening crisis should occur, you agree to contact a crisis hotline, call 911, or go to a hospital emergency room immediately.
You are responsible for protecting your password and access to your phone and/or email account and any text or email you send or receive from CBI to ensure your confidentiality. Your care provider cannot be held liable if there is a breach of confidentiality caused by a breach in your account security.

Consumer/Guardian Signature(Required)

Date(Required)