Client Name: DOB: Intake Date:
Client ID#: Primary Diagnosis: DD Diagnosis: Intake CGAS/GAF:
Maladaptive Targets: 1: 2: 3. 4.
Adaptive Targets: 1: 2: 3. 4.
Intake Forms (all items in regular type must be turned into the office for a case to be opened)
Client Information Sheet
Intake Consents form
No Show Policy
PCP Notification
Release of Information (for case managers)
Behavior Analysis Assessment
Behavior Intervention Plan Target pages (one for each maladaptive & adaptive target)
Personal Safety Plan (if applicable)
Children’s Functional Assessment Rating (CFARS)
Client Rights Pamphlet (give to client/parent)
Health & Safety Pamphlet (give to client/parent)
Adult cases (age 18 and over)
Functional Assessment Rating (FARS)
Session/units used tracking:
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15Date
Date
Follow-up Forms
Due Date / What’s due / When due / Date DoneBehavior Analysis Assessment / Within 30 days after intake date
Behavior Analysis Reassessment / 3 months after intake date
Extension approval by Clinical Supervisor
Behavior Analysis Reassessment
CFARS (FARS for 18+) / 6 months after intake date
(if extending past 6 months)
Extension approval by Clinical Supervisor
Behavior Analysis Reassessment / 9 months after intake date
(if extending past 9 months)
Extension approval by Clinical Supervisor
Behavior Analysis Reassessment
CFARS (FARS for 18+)
Consents: Intake/No Show/Release / 12 months after intake date
(if extending past 12 months)
Treatment Review for Discharge
CFARS (FARS for 18+)
Consumer Discharge Rating
Consumer Satisfaction Survey / Within 15 days after last session if planned discharge
Treatment Review for Discharge / Within 15 days after decision to discharge administratively /
Instructions: This is for you to keep. You can use it to track due dates for this case
DEMOGRAPHIC INFORMATION
Client First Name/Last Name:Social Security#: Birth Date: Age: Sex: Male Female
Address: County:City: State: FL Zip: Email:
Phone: Phone #2: Bilingual needed? no yes:
School: Placement: Reg Ed Emotional/Behavioral Other Exceptional Ed
Race: White Black Native American/Alaskan Asian Pacific Islander Multi-racial
Ethnic: None Puerto Rican Mexican Cuban Other Hispanic Haitian
Legal status: Minor Dependent Minor (foster home) Delinquent Minor Competent Adult Incompetent Adult
FAMILY COMPOSITION
Name Relationship Age Other InformationOther Parent/Guardian: Relationship: Phone:
Address: email:
OTHER CONTACTS
Legal Guardian(s) Name/Relationship*: Phone:
Emergency Contact Name/Relationship*: Phone:
Referral Source: Name/Agency: Phone:
Primary Care Physician: Name/Agency: Phone:
Dependency Case Mgr: Name/Agency: Phone:
Other Case Manager: Name/Agency: Phone:
DJJ Worker/Probation Off: Name/Agency: Phone:
Other MH Counseling: Name/Agency: Phone:
Psychiatric/Medication: Name/Agency: Phone:
School Contact: Name/Agency: Phone:Other: Name/Agency: Phone:
*include address of guardian/emergency contact, if different from above:
FUNDING
Funding Type: Medicaid Healthy Kids Insurance FSPT CMS Other:
Funding Agency:: Subscriber #:ADMINISTRATIVE INFORMATION
Primary Clinician Name: Intake Date: Client ID#:Primary Diagnosis Code: Developmental Disability Diagnosis Code: Intake GAF:
Prior Adapt record(s) for this client filed in discharge year(s):
Updated 06/12
Client Name: Date of Birth:
______(initial) HEALTH & SAFETY: I received a copy of the Health & Safety pamphlet (red), and it was explained to me, including wellness education; Adapt’s policies on substance use, weapons, abuse reporting, emergency procedures; Adapt’s responsibility to respond to client risk of danger to self/others, and after-hours crisis/emergency phone numbers.
______(initial) CLIENT RIGHTS: I received a copy of the Client Rights pamphlet (yellow), and it was explained to me, including what to expect in the assessment, treatment planning, treatment & discharge process; client rights & responsibilities; agency rights & responsibilities; grievance process; treatment philosophy; Primary Clinician name/phone number; and office hours/phone number.
______(initial) LIMITS TO CONFIDENTIALITY: I understand that information about the above-named client will not be shared with anyone without my consent, except under the following conditions:
· Adapt is required to report suspicion of child/elder/disabled adults abuse & neglect.
· Adapt is required to release information for the purpose of abuse/neglect investigations.
· Adapt is allowed to warn potential victims if we believe that their lives are in danger.
· Adapt is required to release a copy of records and/or testimony if subpoenaed in court.
______(initial) COMMUNICATION SECURITY: I understand that Adapt staff are required to use encryption when emailing client information, in order to protect its privacy. I understand that cellular phone communication is not secure, however I authorize Adapt staff to use cellular phones to communicate about the above-named client with me and others that I have approved.
______(initial) STATEMENT OF AUTHORITY TO CONSENT: I certify that I have the legal authority to consent to behavioral health treatment, release of information, and all legal issues involving the above-named client. If my status as legal guardian should change, I will immediately notify Adapt Behavioral Services of the name, address, and telephone number of the person who has assumed guardianship of the above-named client.
______(initial) CONSENT FOR TREATMENT AND TREATMENT LOCATION: I consent for the above-named client to participate in assessment and treatment through Adapt Behavioral Services, including sharing relevant confidential information to coordinate care with others involved in services (e.g., client’s family members, school personnel, other service providers)
______(initial) FUNDING AUTHORIZATION: I authorize Adapt Behavioral Services to release relevant confidential information to my current funding source in order to process claims, obtain reimbursement, and comply with the funding source’s auditing requirements.
______(initial) FINANCIAL RESPONSIBILITY: I understand that I will be responsible for any charges that my funding source does not cover, including any services provided after my insurance has lapsed, fees described on the Copayment Agreement, and fees described in the No Show/Cancellation Policy.
______(initial) OTHER INSURANCE: I understand that publicly funded insurance (Medicaid, Healthy Kids) is payor of last resort and that other insurance coverage must be used first. I understand that I will be responisble for 100% of all charges if I fail to disclose other insurance coverage for the above-named client.
I understand that I may revoke consent for the above at anytime, however, I cannot revoke consent for action that has already been taken. A copy of this release shall be valid as the original.
THIS CONSENT EXPIRES 1 YEAR FROM THE DATE SIGNED.
______
Client/Legal Guardian Signature Date
Client: Date of Birth:
Regular attendance at scheduled appointments is very important. Our services will not be effective in helping you if you do not keep your appointments. Irregular attendance, especially a “no show,” is also inconvenient and costly for the staff assigned to help you. It is therefore your responsibility to attend all scheduled appointments.
CANCELLATION POLICY: If you call your assigned clinician at least an hour before your scheduled appointment, it is considered a “Cancellation,” although 24-hour notice is preferred.
1. After the first cancellation, the staff person will call you to reschedule.
2. After two cancellations in a row, the Director will send you a letter explaining that you must call him/her if you desire to continue services.
3. After the third cancellation in a row, services will be terminated.
4. If you cancel three times, with some attendance in between each cancellation, your therapist will discuss with you some possible solutions to the problem of irregular attendance.
NO SHOW POLICY: If you do not call to cancel at least an hour before the scheduled appointment time, it is considered a “No Show.”
1. If you fail to notify your assigned clinician prior to a missed in-home session, you will be charged a $10 travel fee to cover the staff cost of traveling to your home for the missed appointment.
2. If you fail to notify your assigned clinician prior to an in-office or in-school session, you may be charged a $10 travel fee if the staff traveled to that location specifically for that session.
3. After the first “No Show,” the staff person will call to reschedule the appointment.
4. After the second “No Show,” the Program Manager will send you a letter notifying you that services have been suspended and that you are required to pay the travel fees for both missed sessions in order to reinstate services.
5. After the third “No Show,” your case will be closed.
If these services are mandated or court-ordered, the person responsible for monitoring compliance with the mandate (e.g., dependency case manager, probation officer) will be notified of repeated cancellations/no shows and suspension or termination of services.
I understand Adapt Behavioral Service’s No Show/Cancellation policy and understand that regular attendance is necessary for treatment to be effective. Therefore, I agree to attend all scheduled sessions. If I cannot keep an appointment, I will call the staff 24 hours in advance to reschedule. If I have an emergency that prevents me from attending, I will call the assigned clinician at least one hour before the appointment to cancel.
______
Client Signature Date
______
Parent/Caregiver Signature Date
Client Name: Date of Birth:
This client’s Primary Care Physician is as follows:
PCP Name:
Mailing Address:
City, State, Zip:
Phone/Fax:
Email address:
Purpose of Release:
FOR NOTIFICATION PURPOSES ONLY -- DO NOT SEND RECORDS
This document serves as notification to the Primary Care Physician that counseling, behavior analysis, and/or psychiatric services are being provided by Adapt Behavioral Services:
Intake date:
Clinician Name:
Clinician phone:
Acknowledgement:
By signing below, I authorize Adapt Behavioral Services to release a copy of this document to the PCP named above. I further authorize exchange of confidential information between the PCP and Adapt Behavioral Services for the purpose of coordination of care. Contact information for Adapt Behavioral Services is as follows:
Orange/Seminole/Lake: 225 S. Swoope Ave. #211, Maitland, FL 32751, (407) 622-0444
Volusia/Flagler/St. John’s: 533 N. Nova Rd. #204, Ormond Beach, FL 32174, (386) 898-5003
Osceola/Polk: 3483 W. Vine St., Kissimmee, FL 34741, (407) 928-0444
§ I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment from Adapt Behavioral Services.
§ I understand that I may revoke this authorization in writing at any time, however I cannot revoke authorization for action that has already been taken.
§ A copy of this release shall be valid as the original.
THIS CONSENT EXPIRES 1 YEAR FROM THE DATE SIGNED UNLESS OTHERWISE SPECIFIED.
______
Client/Legal Guardian Signature Date
Client Name: Date of Birth:
I authorize Adapt Behavioral Services
Orange/Seminole/Lake Osceola/Polk Volusia/Flagler/St. Johns
225 S. Swoope Ave. #211 3483 W. Vine St. 533 N. Nova Rd. #204
Maitland, FL 32751 Kissimmee, FL 34741 Ormond Beach, FL 32174
(407) 622-0444 (407) 928-0444 (386) 898-5003
(407) 699-0444 fax (407) 518-0808 fax (386) 675-6490 fax
to exchange confidential information concerning the above-named client with the following:
Agency/Contact:
Mailing Address:
City, State, Zip:
Phone/Fax:
Email:
I authorize:
Informal communication regarding all client information between both parties.
AND/OR
Copies of the following documents to be mailed/faxed to the agency listed above
Copies of the following documents to be mailed/faxed to Adapt Behavioral Services
Limited verbal communication (no copies) related only to the following records
(Check which documents are authorized to be released)
Bio-Psychosocial Evaluation Psychiatric Evaluation Report Cards/Transcripts
Licensed Evaluation Medication Management Behavioral Program
Treatment Plan/Reviews Medical History & Physical Individual Education Plan
Progress Summary Immunization Record Other:
Discharge Review Lab Results Other:
Purpose of Release:
Assessment Treatment Coordination Other, specify:
Notification of compliance with court-ordered treatment (e.g., DCF, DJJ)
§ I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect my ability to obtain treatment from Adapt Behavioral Services.
§ I understand that if I am court-ordered into treatment and refuse to allow Adapt Behavioral Services to share information with those responsible for monitoring my compliance with mandated treatment, this may result in negative consequences imposed by the court.
§ I understand that I may revoke this authorization in writing at any time, however I cannot revoke authorization for action that has already been taken.
§ A copy of this release shall be valid as the original.
THIS CONSENT EXPIRES 1 YEAR FROM THE DATE SIGNED UNLESS OTHERWISE SPECIFIED.
______
Client/Legal Guardian Signature Date
Behavior Analysis Assessment
Client: Date of Birth: Age: Sex: Race:
Lead Analyst: Assessment Start Date: Report Date:
Physician recommending ABA: Diagnosis:
ASSESSMENT PROCESSDocuments reviewed: None, reason:
Diagnostic report (from physician, psychiatrist, psychologist, etc.):
School-related reports (IEP, 504, FBA, testing, etc.):
Other therapy reports (OT, PT, Speech, Counseling, etc.):
Other:
Assessment tools used: None, reason:
FAST MAS CARS Vineland ABLLS VB-MAPP A-DOS Other:
In-Person Assessment:
Interviews with:
Dates of direct observations of the client (2+ observations required):
HOME SITUATION
Type of residence: Number in home: Adults Children
Primary caregiver(s):
Other information:
PSYCHOSOCIAL STRESSORS
Family changes: divorce/remarriage, death/birth, estranged, caregiver changes, other:
Family conflict: between siblings, parent-child, couple/marital, extended family, other:
Social/Relationships: lack of friends, peer conflict/rejection, death/loss of friend, other:
Home Environment: crowded, moves, unsafe, homeless, risk of eviction/foreclosure, other:
Educational: school changes, academic delays, poor grades, discipline, other:
Financial/Work: low income, unemployed, supervisor conflict, retirement, other:
Legal: protective services, arrest, incarceration, probation, litigation, police called, other:
Disability/disorder: SSI, injury, chronic illness, physical limitation, developmental, other:
Trauma/abuse: sexual abuse, physical abuse, foster care, crime victim, natural disaster, other:
Current safety threat (written safety plan required):
Other stressor:
Describe:
DEVELOPMENTAL/MEDICAL/PHYSICAL HISTORY *First 3 items required for children only
*Developmental history: normal, delays in: crawling, walking, speech, other:
*Pregnancy/delivery:
*Immunizations up-to-date (children only): yes no, explain:
Client’s current & past medical issues (check all that apply & provide details below):
none Seizure disorder Hypertension Gross motor problem
Headaches Diabetes Heart problem Fine motor problem
Stomach aches HIV/AIDS Kidney problem Prenatal drug exposure
Bowel problem Brain injury Thyroid problem Life-threatening illness***
Allergies Paraplegia Vision impairment ***(requires safety plan)
Asthma Dental problem Hearing impairment Other:
Details & medications for above:
Family medical history:
Client: