Client Intake

HIPAA (Health Insurance Portability and Accountability Act) protects the privacy of the client's health information. By signing, you acknowledge receiving our Notice of Privacy Practices, which outlines how the client's information may be used and shared for treatment, payment, and healthcare operations.

This authorization allows us to communicate with the client's insurance company or healthcare providers as necessary to coordinate care, verify eligibility, and process payments. We will only disclose the minimum amount of information needed and will ensure all staff comply with confidentiality requirements.

You may revoke this authorization in writing at any time, and the client's services will not be affected if you choose not to authorize non-essential disclosures.

Therapy is most successful when families are actively involved. Signing this agreement indicates that you understand the importance of participating in training sessions, applying strategies at home, and communicating with the client's therapy team.

Family training helps generalize skills outside of therapy sessions and creates consistency for the client. This collaboration ensures we are targeting meaningful goals and adapting plans as the client develops.

Your involvement may include observing sessions, completing activities with the client, attending family trainings, and reviewing progress with the BCBA.

Failure to participate may impact the client's progress and eligibility for continued services.

This form authorizes Adams Behavioral Consulting LLC to submit claims and receive payments directly from the client's health insurance provider. It ensures timely and consistent reimbursement for services rendered and allows us to manage all billing and documentation with the insurance company.

You are still ultimately responsible for any co-pays, deductibles, or balances not covered by insurance. We recommend confirming your benefits and coverage to avoid unexpected charges. This authorization can be revoked in writing at any time.

Attendance requirements

Clients are expected to attend all scheduled sessions. Consistent attendance is crucial for treatment success. Excessive absences without valid reason may result in discharge from services.

Cancellation policy

A minimum of 24 hours' notice is required for all cancellations. Failure to provide adequate notice may result in a cancellation fee. Repeated last-minute cancellations or no-shows may lead to review of service eligibility.

Behavior expectations

Clients and families are expected to treat staff with respect. Aggressive or threatening behavior will not be tolerated and may result in termination of services.

Confidentiality guidelines

We are committed to protecting the client's private information. All records and communications are handled according to HIPAA regulations. Information will only be shared with your written consent unless required by law.

Grievance procedures

If you have a complaint or concern, please speak directly with your BCBA. If the issue is not resolved, you may request a meeting with leadership. A written grievance form is available upon request.

Illness protocols

If the client is sick (fever, vomiting, diarrhea, contagious condition), please cancel the session. Sessions may be rescheduled once the client is symptom-free for 24 hours without medication.

With your consent, we may record therapy sessions to support staff training, clinical documentation, and treatment planning. These recordings will be used exclusively by Adams Behavioral Consulting LLC.

This internal review process enhances the quality and accuracy of our service delivery by allowing supervisors to monitor interventions and ensure treatment fidelity.

No images, audio, or video will be shared outside of the clinical team unless you sign an additional release form. You may opt out of this at any time without any negative effect on the client's services.