Dear Parent/Guardian,
Thank you for choosing Children’s Autism Center for your child. Enclosed in this packet is everything that you will need to complete and an explanation of our application process.
To begin the process, you will need to complete the following items in this packet:
- Enrollment application – please complete in full
- Assignment of Benefits and Release of Information Form for medical information needed for insurance
- Consent to Release Information – to be able to access information from other pertinent agencies such as school, doctors or other service provider that will help as we develop the treatment plan
- Payment Policy – please read and sign
- Self- care checklist
- Home situations Questionnaire
- Parent Training enrollment form – PARENT TRAINING IS REQUIRED. Additional information is included in this packet
Next – you will need to provide the following to In-Take in order to complete the application phase of the process:
1.)Initial or most recent diagnosis report from the diagnosing physician or clinician- this report must contain the following:
- Diagnosis of Autism – stated clearly with the diagnosis code for autism
- Test used to diagnose autism
- Diagnosing doctor’s signature
2.)Copy of insurance card/cards
3.)Fee - $25.00 (enrollment fee)
If you would like a tour of the Children’s Autism Center – please call 459-6040 to schedule a tour.
Thank you for your interest in the Children’s Autism Center – if you have any questions during this process, please contact me at 459-6040.
Sincerely,
LouAnn B Stone
Intake Coordinator/Family Support Specialist
Additional Information for you:
The Children’s Autism Center has four locations:
South – 10313 Aboite Center Road, Fort Wayne -located at the Jorgensen YMCA
North –10820 Coldwater Road, Fort Wayne
Angola – 150 Growth Parkway, Angola
Columbia City – now accepting applications
Please indicate on the application which location you prefer.
Parent Training
The goal of parent training is to equip parents/caregivers with the principles of applied behavior analysis(ABA) for application at home or in other natural environments. Following is more specific information for parent training:
Parent Training Protocol 1 (Introduction): This protocol, based off of Parent Training for Disruptive Behaviors (Bearss, Johnson, Handen, Butter, & Lecavalier, 2015), provides a 12 week course on the basic principles of ABA. It also covers advanced topics such as feeding, sleeping and crisis management.
Parent Training Protocol 1 includes an Aberrant Behavior Checklist – Community and the Home Situations Questionnaire at the beginning and end of the training.
Make –up sessions will occur in a subsequent training session or individually. It is highly recommended that you attend every session for maximum benefit.
The instructors are Board Certified Behavior Analyst, Board Certified Assistant Behavior Analyst, Speech Language Pathologist, and students in the process for these certifications.
The cost of these sessions may be billed to insurance or the cash payment is $220.00. This includes a workbook, assessment results, and a home visit. Parents on the waitlist may use the code WAIT LIST for a discount rate.
Application Process and Time Line for each phase
First Step – Application Phase
Approximately 2-3 days
Second Step – Assessment phase
Time frame 2-4weeks
Third Step – Treatment Plan Phase
Enrollment Application
Information provided will be kept confidential by the staff of the Children’s Autism Center, Inc., unless authorized by parents/legal guardians of the client.
Date of Application: ______
Program(s) DesiredABA/Verbal Behavior:
□ Comprehensive/Full Time (30-40 hours/week)
□ Focused/Part Time (5-29 hours/week)
□ Peers Social Skills Group with Social Coach
□ Peers Social Skills Group - no Social Coach
□Speech (speech is only offered to ABA clients and cannot be requested as a stand-alone therapy)
Site Preferred: □ South (Jorgensen YMCA) □ North (Coldwater Road) □ Angola □ Columbia City
Client Information
Last Name: / Date of Birth:
First Name: / Gender:
Middle Initial: / Address:
Name preferred/nickname: / City:
Home Phone: / State: Zip:
Mother or Legal Guardian Information
Full Name: / Relationship to Client, if guardian:
Address:
City: / Occupation:
State: Zip: / Employer:
Home Phone: / Work Phone:
Cell Phone:
Email: / Can we send information via email?
Father or Legal Guardian Information
Full Name: / Relationship to Client, if guardian:
Address:
City: / Occupation:
State: Zip: / Employer:
Home Phone: / Work Phone:
Cell Phone:
Email: / Can we send information via email?
Child/client lives with:
□Both parents □Mother □Father □Other______
Client’s Siblings
Name / Age / Gender
Source of Funding / Early Intervention Medical Insurance Private Pay
Medicaid Med/Autism/DD/SS Waiver Other:
Medical Insurance Provider
Policy # / Group# / Plan Name
Current Pediatrician or General Practitioner: / Physician Phone Number:
Physician Address:
Diagnosing Dr.: / Primary Diagnosis: Date of Diagnosis:
Address: / Phone #:
Is your child currently or in the past been diagnosed with an infectious disease?□ Yes□ No
If yes, please explain: / Date of Diagnosis:
Has your child been diagnosed with allergies? If yes, please indicate allergen. □ Yes □ No / Date of Diagnosis:
Other condition: / Date of Diagnosis:
Medication Information
Is the client on medication? □ Yes □ No
If yes, list medication information below:Medication / Dosage / Time Administered / Purpose
Will any of the above medication need to be administered during attendance at Children’s Autism Center?
□ Yes □ No
Has the client ever been admitted to a hospital/treatment center for psychiatric, behavioral, or crisis situation? □ Yes □ No If yes, please explain.
Please summarize the hospital/treatment center’s treatment and effectiveness of treatment:
Are there any medical conditions that need to be considered when client is in ABA therapy or speech therapy: □ Yes □ No If yes, please explain.
Therapies and Services
What other services are your child currently receiving? Please include all services, including school based.
Service/Therapy / Location
□ Verbal Behavior/ABA services
□ Early Intervention services
□ Speech/language therapy
□ Occupational therapy
□ Physical therapy
□ Developmental therapy
□ Other______
Please describe the results of these therapies in regards to success in achieving goals.
What are your immediate goals for your child?
______
What level of commitment are you willing to make at home in order for your child to achieve these goals? ______
What would you like us to know about your child? Please include likes and dislikes.
______
What, if any, behavior issues does your child have? For example: self-injurious, aggression, lack of attention, or other.
______
Is there anything your child is fearful of? ______
What current communication skills does your child have? For example: sign language, PECS, or verbal.
______
______
CAC is a non-profit organization, and relies on volunteer efforts. Are there any talents, interests, professional training, or resources you would be willing to share?
______
The programs at CACdepend on parent participation. We require each family to attend team meetings (monthly or as needed), and parent trainings so that effective teaching will continue in the home. The more parents/guardians know about ABA and treatment procedures here at CAC, the more the child will benefit.
Professional Crisis Management or PCM
PCM crisis management procedures may be used with your child in the event of extreme behaviors that may endanger your child, other clients, staff, and/or property. Any CAC staff who will be utilizing PCM techniques is PCM trained and certified. If you have any questions or would like to see a demonstration of PCM techniques, we are happy to assist. A PCM authorization must be received by our office prior to your child’s attendance at our center.
For more information on PCM, see
The undersigned hereby acknowledge that the information contained in this application is accurate in all respects.
Parent/Guardian (print name):______
Signature of Parent/Guardian):______
Date:______
The following documents/items must be completed and received
in order for this application to be processed.
This enrollment application
Signed “Assigment of Benefits and Release of Information” form
? Signed Consent to Release Information Form
Signed “Payment Policy” form
Initial or Most Recent Diagnostic Report
Completed Home Situations Questionnaire
? Completed Self Care Checklist
Copy of the front and back of your insurance card
Cash/Check for $25.00 (non-refundable application fee)
Please mail all of the above to:
Children’s Autism Center, Inc.
10313 Aboite Center Rd
Fort Wayne, IN 46804
Office use onlyDate received ______Initials ______Incomplete? Y / N Follow up sent ______
Assignment of Benefits and Release of Information
Client Name:Client Date of Birth:
Insurance Company:
Policy Number: Group Number:
Insurance Company Address:
Insurance Company Phone:
Insured’s/Guarantor Name:
Insured’s Date of Birth:
Insured’s Employer:
I authorize the release of any medical or other information necessary to process my medical claim. I authorize payment of medical benefits to Children’s Autism Center, Inc., for services which facility and /or employees provide. I understand I am financially obligated to pay for all services provided by Children’s Autism Center, Inc. and/or its employees.
Authorized Signature:______
Printed Name:______
Date:______
Consent to Release Confidential Information
Client: ______
I authorize Children’s Autism Center, Inc. to release information to the client’s insurance company in order to receive payment for services.
Parent/Guardian: ______Date: ______
Witness: ______Date: ______
I authorize Children’s Autism Center, Inc. to release information to and/or receive information from the primary care physician and from the following (school, psychologist, therapist, etc.) to coordinate care:
Name: ______Name: ______
Address: ______Address: ______
______
Phone: ______Phone: ______
Relationship: Primary Care Physician Relationship: ______
Name: ______Name: ______
Address: ______Address: ______
______
Phone: ______Phone: ______
Relationship: ______Relationship: ______
Unless you specifically list otherwise, we will assume that the above individuals have your permission to see all of the client’s evaluations/reports completed by Children’s Autism Center, medical/psychological records, school reports and other therapy/counseling reports.
I understand that these records may contain psychiatric and/or drug and alcohol information, and/or information related to blood born pathogens (ex. HIV, AIDS)
I understand that the disclosed information will only be used for professional purposes and will remain confidential.
I understand that I may revoke this consent at any time, but I cannot revoke consent for action that has already occurred.
I verify that a copy of this release shall be as valid as the original. This consent remains valid for 90 days following the completion of services by Children’s Autism Center, Inc.
Parent/Guardian: ______Date: ______
Witness: ______Date: ______
Payment Policy
Children’s Autism Center, Inc. (“CAC”) is a nonprofit organization dedicated to providing the highest quality, medically supported therapy to children of all ages with autism and developmental/language delays in Northeast Indiana. As part of this mission, we are committed to keeping our business expenses as low as possible and we appreciate the role our clients have in this effort. To this end, CAC has established the following Payment Policy.
Our standard hourly rates are subject to change without notice and are as follows:
ABA Therapy$72.00/hour
Consultant (BCBA/BCaBA)$160.00/hour
Speech Therapy$74.00/hour
School Aide $16.60/hour
Travel $0.25/mile
At the time you register with CAC, a non-refundable registration fee of $25 is due.
In most cases, we will file insurance claims for those insurance plans with which we are contracted. In some instances, we will ask assistance from the insured in dealing with the insurance carrier in an effort to maximize benefits.
We understand that our services can be expensive and sometimes unplanned. CAC is willing to work with our clients in establishing a payment plan. Clients are encouraged to make these arrangements as soon as possible.
Payment for services rendered is expected within 30 days from the receipt of your monthly statement. This policy applies to the full range of services rendered by CAC.
Patient balances that remain unpaid after 45 days may be sent to a collection agency for further action and the client discharged from CAC services.
In the event that the client does not insurance, a cash pay discount can be applied.
By signing below, you acknowledge that you have received and reviewed our Payment Policy.
Signature: ______
Printed Name: ______
Date: ______
SELF-CARE CHECKLISTS
The focus of the VB-MAPP is primarily on communication and social skills. However, self-care skills are an important part of the child’s growing independence. The following self-care checklists can be used for assessment and skills tracking. The list can be downloaded and printed as needed to complete your child’s program. As always, the procedures derived from applied behavior analysis provide the best way to teach these skills.
Children’s Autism Center Note:
Please date the skills your child currently has. If the skill is inconsistent or questionable, please error on the side of not considering it mastered so that we will work on the skill in our program.
Print as Needed VB-MAPP Supplement - Self-care
DRESSING – BY ABOUT 18 MONTHS
___ Pulls a hat off
___ Pulls socks off
___ Pulls mittens off
___ Pulls shoes off (may need help with laces, buckles and velcro straps)
___ Pulls coat off (may need assistance unbuttoning and unzipping)
___ Pulls pants down (may need assistance unbuttoning and unzipping)
___ Pulls pants up (but may need help getting pants over a diaper, and with buttoning, snapping and zipping)
DRESSING – BY ABOUT 30 MONTHS
___ Unties shoe laces
___ Unbuttons front buttons
___ Unsnaps
___ Fastens and unfastens velcro
___ Unzips front zippers (smaller zippers may be difficult)
___ Removes shirt (tight shirts may require assistance)
___ Removes pants or skirts (may need help unzipping and unbuttoning)
___ Puts on shoes (needs help discriminating right from left and tying)
___ Puts on pants (may need help zipping and buttoning up)
___ Adjusts clothing
___ Matches own socks
___ Matches own shoes
___ Puts dirty clothes in a hamper
DRESSING – BY ABOUT 48 MONTHS
___ Undresses (but may need help with tight pullover clothes)
___ Dresses (may need help with back buttons and zippers such as on a dress)
___ Puts on coat
___ Puts on socks
___ Puts on pants
___ Buckles and unbuckles most buckles (some may be more difficult)
___ Zips and unzips front zippers
___ Buttons and unbuttons front buttons
___ Snaps and unsnaps front snaps
___ Identifies which clothes to wear for various weather conditions
___ Attempts to lace shoes
___ Puts on shoes (discriminating right from left with a prompt)
___ Attempts to tie shoes
___ Hangs up own clothes on a hook
___ Hangs up own clothes on a hanger (with assistance)
___ Folds own clothes (with assistance)
___ Puts clothes in drawer
Print as Needed VB-MAPP Supplement - Self-care
BATHING AND GROOMING – BY ABOUT 18 MONTHS
___ Wipes nose with a tissue (with assistance)
___ Washes hands (with assistance)
___ Dries hands (with assistance)
___ Attempts toothbrushing (with assistance)
BATHING AND GROOMING – BY ABOUT 30 MONTHS
___ Attempts to use a washcloth and soap while bathing (with assistance)
___ Brushes teeth (with assistance)
___ Washes face (with assistance)
___ Dries face
___ Attempts to wash hands independently
___ Dries hands
___ Attempts to brush hair (with assistance)
BATHING AND GROOMING – BY ABOUT 48 MONTHS
___ Wipes nose with a tissue and puts it in the trash
___ Gets in and out of a bath tub with minimal assistance
___ Uses a washcloth and soap when bathing
___ Washes hair (with assistance, especially for longer hair)
___ Dries self after a bath or shower
___ Brushes teeth
___ Flosses teeth (with assistance)
___ Washes hands
___ Washes face
___ Dries both face and hands
___ Hangs up towel after washing
___ Brushes hair (with assistance, especially for longer hair)
Print as Needed VB-MAPP Supplement – Self-care
FEEDING – BY ABOUT 18 MONTHS
___ Eats finger foods
___ Drinks from a cup by self
___ Uses a spoon to scoop food
___ Sucks from a straw
FEEDING – BY ABOUT 30 MONTHS
___ Uses a fork to pick up food
___ Uses a napkin to wipe face and hands
___ Carries own lunch box or plate to table
___ Opens own lunch box
___ Opens ziploc bags
___ Unwraps partially opened food packaging
___ Puts a straw into a juice box
___ Peels a banana
___ Takes off own bib
FEEDING – BY ABOUT 48 MONTHS
___ Uses the side of a fork to cut softer foods
___ Uses a knife for spreading
___ Uses a knife for cutting (softer foods)
___ Keeps eating area reasonably clean while eating
___ Unwraps most food packaging
___ Opens milk or juice container
___ Pours liquids into a cup or bowl (from a small pitcher or lunch thermos)
___ Helps to prepare simple foods (spreading, stirring, using cookie cutters, holding a beater, measuring ingredients, pouring ingredients)
___ Helps to set the table for meals
___ Takes dishes to the sink
___ Wipes the table with a sponge or dish towel
Print as Needed VB-MAPP Supplement – Self-care
TOILETING – READINESS SKILLS - BY ABOUT 24 MONTHS
___ Responds to reinforcement
___ Follows simple directions
___ Seems uncomfortable in soiled diapers
___ Remains dry for 2 hours at a time
___ Bowel movements are predictable and regular
___ Pulls pants down
___ Pulls pants up
___ Can sit still for 2 minutes at a time
TOILETING – BY ABOUT 36 MONTHS