Client Intake

• Minimum of 3-4 hour sessions required/Minimum of 15-35 weekly hours required
  (Monday-Friday) required depending on the clients medical necessity and ABA prescription.
• Please list availability for August-May of the current year below
• Weekend Hours are subject to staff availability

Clients are often pulled based on availability listed and location provided, if the information provided changes at any time, please report the changes to admin@cbiaba.com.

Clients are often pulled based on availability listed and location provided, if the information provided changes at any time, please report the changes to admin@cbiaba.com.

Clients are often pulled based on availability listed and location provided, if the information provided changes at any time, please report the changes to admin@cbiaba.com.

Clients are pulled based on availability and location provided on the intake packet. If this information changes, it must be reported to admin@cbiaba.com immediately. Changes to availability and schedules directly impact our ability to pull a client.

Schedules must be placed in one of the following combinations:
- Monday, Wednesday, Friday
- Tuesday Thursday
- Monday-Friday

Available hours must align with the prescribed amount of hours listed on the recommendation from your doctor or psychologist. New clients will typically start with 30-35 hours. Hours are reduced as the client meets their goals and prepare for discharge from services.

Any change in hours during the course of treatment could result in loos of services as teams are specifically placed based on a clients availability. If morning hours are listed on the intake packet, CBI will require that morning hours be available for services. If availability differs from what is provided on the intake packet, services may not be able to be provided to the client. Please provide accurate availability on all forms.

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.

Carolina Behavioral Innovations, LLC does not require staff to disclose weather or not he/she has received any vaccinations. Please keep in mind we will do our best to accommodate any request, however, cannot guarantee the availability of vaccinated staff.

Emergency Contact

Has your child had any history of the following?
Check Yes or No. If yes, please provide approximate age and description.

Has your child had any history of the following?
Check Yes or No. If yes, please describe the results.

Has your child ever received evaluations or therapy from any of the following services?

Please describe your child’s performance in the following skills.

Birth to 6 months:

7 months to 3 years: Please complete the following:

Thank you for taking the time to complete this form.

Lack of parental involvement is detrimental to a child’s development and progress within an the program. Many research studies have demonstrated that when parents are actively involved in their child’s therapy program, the results are increased developmental skills, improvements in progress, reduced conflict and stress inside of the home, and increased reports of marital satisfaction. The benefits of parental involvement in therapy are varied and multiple, as are the detriments of a lack of parental involvement in therapy.

The role of the therapist, paraprofessional, OT, ST, BCBA, or BCaBA, is to guide, oversee, and design programs, or to implement programs as a part of therapy. The ultimate responsibility for the effectiveness, generalization, and maintenance of skills taught and behaviors reduced using methodologies lies with the parents.

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:

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

1. Email messages may not be received.
2. Email can be circulated, forwarded and stored in numerous paper and electronic files, in intended and unintended ways
3. Senders can easily misaddress an email message
4. Email messages can be immediately broadcast worldwide and received by many intended and unintended recipients
5. Email can be easier to falsify than handwritten or signed documents
6. Back-up copies of email may exist even after the sender or the recipient has deleted his or her copy
7. Email can be used as evidence in court
8. Email can be intercepted, altered, forwarded or used without authorization or detection
9. 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.

1. Email and/or text message correspondence must be specifically requested and initiated by the consumer or the minor consumer’s parent/guardian.
2. Your care provider shall not email or text any Protected Health Information unless you specifically request him/her to do so.
3. Any email that you send that discusses your diagnosis or treatment constitutes informed consent to the information being transmitted.
4. Emails and/or text messages containing clinical content will become a part of your medical record.
5. 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.
6. You are responsible for informing the provider of any types of information that you do not want sent by text message and/or email.
7. 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.
8. You may withdraw consent to communicate by text or email via written communication to the provider at any time.
9. If a life-threatening crisis should occur, you agree to contact a crisis hotline, call 911, or go to a hospital emergency room immediately.
10. 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.

Carolina Behavioral Innovations is committed to being a culturally competent organization. Cultural encompasses philosophy, beliefs and practices that ‘show up’ across many different areas of our company. One such area is in relation to the families we serve. We invite parents to contribute to the content of their child’s treatment plan in order to teach their child content relevant to his/her family’s cultural practices. We also ask parents to describe cultural practices that are important for our staff to respect.

CBI is deeply committed to developing both a clientele and staff team who are culturally diverse. We have provided services to families with very diverse backgrounds and continue to tailor our hiring practices in a way that best promotes a diverse pool of qualified and highly competent applicants.

We are very proud of our diverse staff team. Your child’s team may be comprised of staff with different backgrounds, beliefs and experiences. While it is vital that the families we serve feel comfortable with their child’s team of staff it is of equal importance that our staff receive appropriate respect and opportunities due them as professionals in their field, regardless of their cultural background. It is for these reasons that we invite you to share with us before initiating services of any particular traits and/or characteristics that you would prefer us to take into consideration when staffing people to work with your child. We can then plan your schedule accordingly while insuring that staff are appropriately scheduled.

We welcome the opportunity to grow through our partnership with you, your child, and our highly competent and diverse team of staff.

Carolina Behavioral Innovations, LLC (CBI) provides ABA services to clients whom choose to participate in services. All clients have the right, at any time, to choose their service provider.

Carolina Behavioral Innovations, LLC does not participate or provide any type of retroactive billing to Medicaid beneficiaries.

By signing below, you accept and understand that the client and/or client guarantor is responsible for all out of pocket expenses that are incurred in the time that the client is waiting on Medicaid approval. Carolina Behavioral Innovations, LLC does not back bill Medicaid to a retroactive approval date for any reason.

Carolina Behavioral Innovations, LLC will begin to bill Medicaid once a client is approved and CBI has completed all necessary assessments and received an ABA authorization from Medicaid to bill services.

The parent should notify CBI immediately once Medicaid is approved and send the Medicaid approval to admin@cbiaba.com.

In consideration of the participation of the child named above (the “Child”) in programs and activities provided by Carolina Behavioral Innovations, LLC (the “Provider”) at its facility located at 14 Progress Drive, Greenville, SC, and at any other location or function associated with Carolina Behavioral Innovations, LLC, the undersigned acknowledges and agrees as follows:

1. Assumption of Risk

I, the undersigned, understand that participation in programs and activities provided by Carolina Behavioral Innovations, LLC, which serves children with moderate to severe maladaptive behaviors, involves inherent risks of injury. These behaviors may include, but are not limited to, physical aggression, self-injurious behavior, and other forms of disruptive actions that could pose risks to the Child and others around them. The nature of these programs, especially when conducted in group settings with other children, carries additional risks of injury or harm due to possible interactions among participants. I assume all risks associated with the Child’s participation, both known and unknown, and voluntarily allow the Child to participate with the full understanding of these risks.

2. Waiver and Release of Liability

I, on behalf of myself, my child, and our heirs, executors, administrators, and assigns, hereby release, discharge, and hold harmless Carolina Behavioral Innovations, LLC, its owners, employees, agents, representatives, successors, and assigns from any and all claims, damages, liabilities, or expenses arising from any injury, illness, loss, or damage to the Child or their property in connection with their participation in the programs and activities at 14 Progress Drive, Greenville, SC, or at any other location or function associated with Carolina Behavioral Innovations, LLC, whether arising from negligence or otherwise.

3. Medical Consent

In the event of a medical emergency, I consent to the provision of first aid or medical treatment for the Child as deemed necessary by appropriate personnel of Carolina Behavioral Innovations, LLC, whether on-site at 14 Progress Drive, Greenville, SC, at another affiliated location, or at a nearby medical facility. For non-life-threatening situations, I request that reasonable efforts be made to contact me (or another designated caretaker) prior to administering treatment. I understand that I am responsible for all costs related to medical treatment for the Child.

4. Indemnification

I agree to indemnify and hold harmless Carolina Behavioral Innovations, LLC, its employees, and agents from and against all claims, damages, losses, and expenses arising from the Child’s participation in the programs and activities at 14 Progress Drive, Greenville, SC, or at any other location or function associated with Carolina Behavioral Innovations, LLC, including reasonable attorney fees.

5. Governing Law

This Agreement shall be governed by and interpreted in accordance with the laws of the State of South Carolina.

6. Acknowledgment of Understanding

I have carefully read and fully understand this Agreement and voluntarily agree to its terms. I am aware that by signing this document, I am waiving certain legal rights on behalf of myself and the Child.

Introduction

Thank you for choosing Carolina Behavioral Innovations, LLC for your child’s therapeutic services. This informed consent form is intended to provide you with essential information about the therapies your child may receive, including Applied Behavior Analysis (ABA) Therapy, Speech Therapy, and Occupational Therapy. It also includes a waiver of assumption of risk for ABA therapy.

Please carefully read and review the information below and provide your consent for treatment.

1. Therapy Overview

Applied Behavior Analysis (ABA) Therapy: ABA therapy is an evidence-based intervention designed to improve various behavioral, social, and communication skills in children with autism spectrum disorder (ASD) and other developmental conditions. ABA therapy typically involves identifying specific behaviors to increase or decrease, setting measurable goals, and using techniques such as reinforcement, prompting, and shaping to achieve those goals.

Speech Therapy: Speech therapy focuses on helping children improve their communication skills, including speech, language, and social communication. It may address issues such as articulation, fluency, receptive/expressive language, and pragmatic (social) language skills.

Occupational Therapy (OT): OT helps children develop the skills necessary for daily living, including motor skills, self-care, and sensory processing. Occupational therapists may work on activities such as fine motor coordination, hand-eye coordination, sensory integration, and improving functional independence.

2. Consent for Treatment

By signing this form, I give my consent for Carolina Behavioral Innovations, LLC to provide the selected therapy services (ABA therapy, speech therapy, and/or occupational therapy) to my child. I understand that my child’s therapy plan will be individualized based on their specific needs and goals and that progress will be monitored regularly.

3. Assumption of Risk for ABA Therapy

I acknowledge that Applied Behavior Analysis (ABA) Therapy involves certain risks and challenges, as detailed below, and that such risks are inherent to the therapy process. These may include:

• Emotional and Behavioral Responses: My child may experience emotional reactions such as frustration, anxiety, or resistance to certain interventions. Such responses are common in ABA therapy but typically decrease over time as progress is made.
• Challenging Behaviors: As part of ABA therapy, behaviors such as aggression or self-injurious behavior may be addressed. My child may initially display these behaviors in response to therapeutic techniques.
• Social Interactions: ABA therapy often involves social skills training, and my child may experience challenges interacting with peers or therapists during this process.
• Discomfort or Fatigue: Some interventions in ABA therapy may lead to temporary fatigue or mild discomfort, particularly during intensive sessions or new behavioral strategies.
• Time Commitment: Successful ABA therapy may require a significant time commitment on my part, including attendance at therapy sessions, parent training, and home practice.

By signing below, I voluntarily accept these risks and understand that they are part of the ABA therapy process.

5. Informed Consent for Speech and Occupational Therapy

I consent to my child receiving Speech Therapy and/or Occupational Therapy as deemed necessary by the therapy team. I understand that these therapies aim to address specific developmental, communication, and motor challenges. I acknowledge that these services will be provided by licensed professionals and that my child’s progress will be regularly assessed.

6. Parent/Guardian Involvement

I understand that active participation and cooperation with the therapy team, including attending parent training sessions, following through with home practice activities, and providing feedback, are vital for the success of my child’s therapy.

4. Release of Liability

I agree to release and hold harmless Carolina Behavioral Innovations, LLC, its staff, agents, and affiliates from any liability for injury, loss, or damage that may occur as a result of ABA therapy services provided, except in cases of gross negligence or willful misconduct.

I understand that all staff at Carolina Behavioral Innovations, LLC will adhere to professional standards in providing therapy and will take all necessary precautions to ensure my child’s safety during sessions.

7. Emergency Medical Care Consent

In the event of a life-threatening emergency, I give consent for Carolina Behavioral Innovations, LLC to contact emergency medical services (EMS) or to take necessary action to ensure my child’s safety, including seeking medical treatment if required. I agree to bear the responsibility for any medical costs incurred.

In the event of a non-life-threatening emergency, Carolina Behavioral Innovations, LLC staff will contact the emergency contact on file first, to request the caregiver's direction to come pick up the child to receive medical attention.

8. Voluntary Participation and Right to Withdraw

I understand that participation in therapy is voluntary, and I have the right to withdraw my consent for therapy services at any time, without penalty, though I acknowledge that discontinuation may impact the overall effectiveness and progress of my child’s treatment plan.

9. Confidentiality and Privacy

I understand that the therapy services provided to my child will be confidential, and all information about my child’s therapy progress will be handled in accordance with HIPAA regulations and other applicable laws. I also understand that I will receive periodic updates on my child’s progress.

10. Restraint Policy Acknowledgement

Carolina Behavioral Innovations, LLC does not use or administer restraint procedures under any circumstances. In the event of a medical or behavioral emergency, our staff is trained to administer appropriate first aid, provide assistance, or seek emergency services if necessary, but restraint procedures will never be applied. I understand that should a situation arise where restraint might be considered, appropriate emergency or law enforcement personnel will be contacted immediately.

11. Parent/Guardian Declaration

By signing this form, I confirm that I have had the opportunity to ask questions about the therapy services, risks, benefits, and alternatives, and that all of my questions have been answered to my satisfaction. I acknowledge that I understand the nature of the therapy services, including ABA therapy, and voluntarily consent to my child’s participation in these services.

Preferred Hospital (in case of emergency):

Please provide the name and contact details of the hospital you would prefer to be taken to in case of a medical emergency:

Acknowledgement of Receipt

I acknowledge that I have received a copy of this Informed Consent for Therapy Services form, including the waiver of assumption of risk for ABA therapy.