School Services Agreement

Client Name: School Name:

School Placement: Reg. Ed. EBD EMH TMH SLD VE Other:

Staff Name: Staff Job Title: Behavior Analyst Therapist

For more information on staff credentials, call the Human Resources Manager at (407) 622-0444 x104.

BEHAVIOR ANALYSIS: BA services are typically provided within the classroom setting and do not involve removing the student from the classroom. The BA is a consultant who works with the teacher to identify behavioral interventions to be used in the classroom that will reduce the identified student’s problem behavior. Assessment usually involves direct observation in the classroom, and interviews with the student and the teacher to identify triggers, behavioral patterns, possible reinforcers, previous interventions, and classroom structure/curriculum. Treatment usually begins with the BA taking a more hands-on approach with the student that fades as the teacher begins implementing the behavioral program him/herself.

THERAPY: Therapy services are typically provided outside of the classroom in a private area alone with the student. The individual therapy with the student is integrated within the school setting through ongoing discussions with the teacher and other involved school staff regarding client problems, progress, and interventions/approaches used in the school to help with the student’s problems. The Therapist also serves as a consultant who works with the teacher to identify ways to handle the student in the classroom that will help reach treatment goals.

Expected duration and frequency of services: hour(s) per week for months

Rationale for services in the school:

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I verify that I am the legal guardian for the above-named child. I give my consent for Adapt Behavioral Services staff to provide services at this child’s school.

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Legal Guardian Date

I have been informed that all staff of Adapt Behavioral Services have completed a Level II background screening required by the State of Florida. I give permission for these services to be provided in the school by the above-named staff.

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Principal Date School Primary Contact Date

(required if non-contracted school)

Revised 02/13