Intake – BBehavior

Thank you for Choosing BBehavior

The form below helps our clinical team understand your loved one’s needs, history, and goals, so we can build a care plan that’s truly personalized from day one. Please complete it as thoroughly as you can so we can hit the ground running together.

Please fill out the below form to get started

Child Information

Child Full Name

Preferred Name (If any)

Date of Birth:

Gender

Country/Region

Address

City

Zip / Postal code

Parent / Guardian Information

Parent / Guardian Full Name

Relationship to Child

Phone Number

Email Address

Preferred Contact Method

Call Text Email

Primary Diagnosis / Reason for Referral

Date of Diagnosis (if known)

Other Diagnoses (if applicable)

Physician / Provider Email

Physician / Provider Phone Number

Insurance Information

Primary Insurance Provider

Member ID / Policy ID

Group Number (if applicable)

Relationship to Child

Policy Holder Name

Date of Birth (Policy Holder)

Insurance Phone Number

Policy Holder Employer (if applicable)

Insurance Address (if different from above)

Does your plan require a referral for ABA services?

Is ABA therapy covered under this plan?

Have you checked your out-of-pocket costs?

Legal & Concern

1. HIPAA Acknowledgment

BBehavior may use and disclose protected health information (PHI) for treatment, payment, and healthcare operations as permitted or required by law.
My child's protected health information may include medical, developmental, behavioral, treatment, insurance, billing, and service-related information.
BBehavior is required by law to protect the privacy and security of protected health information, follow the privacy practices described in its Notice of Privacy Practices, and notify me if a breach occurs that may compromise the privacy or security of my information.
I understand that I can obtain a paper copy of the Notice of Privacy Practices at any time by asking a staff member or by contacting our office.
I understand that signing this acknowledgment does not authorize the release of information beyond what is permitted by law or described in the Notice of Privacy Practices.

I acknowledge that I have received or been given access to BBehavior's Notice of Privacy Practices.

2. Consent for ABA Services

Authorization for ABA Assessment and Therapy Services

Please read the following information carefully. By signing below, you give consent for BBehavior to provide ABA services for your child.

I give permission for BBehavior to provide Applied Behavior Analysis (ABA) services for my child.
Services may include intake review, parent interview, observation, assessment, behavior assessment, skill assessment, treatment planning, caregiver training, direct ABA therapy, supervision, progress monitoring, and coordination of care.
I understand that ABA services may be provided by qualified staff under appropriate supervision, including Board Certified Behavior Analysts (BCBAs), Assistant Behavior Analysts (BCaBAs), Registered Behavior Technicians (RBTs), behavior technicians, trainees, or other authorized clinical team members.
I understand that ABA therapy is individualized and may include teaching communication, social, adaptive, play, safety, behavior reduction, and daily living skills.
I understand that treatment recommendations may change based on assessment results, insurance authorization, clinical need, family availability, and progress.
I understand that participation from parents or guardians is important for treatment success.
I understand that I may ask questions about services at any time.

I give consent for BBehavior to provide ABA assessment and therapy services for my child.

3. Parent / Guardian Agreement

Please read the following agreement carefully. By signing below, you agree to the terms and conditions for services with BBehavior.

BBehavior will provide services based on clinical recommendations, availability, insurance authorization, and family participation.
I agree to provide accurate and complete information regarding my child's medical history, diagnosis, insurance, emergency contacts, medications, allergies, behavioral concerns, family goals, and any other information relevant to services.
I agree to notify BBehavior of any changes in insurance, address, phone number, medical condition, medications, custody arrangements, emergency contacts, school placement, or service needs.
I understand that parent or caregiver involvement may be required, including participation in parent training, treatment planning, progress updates, and supporting skill generalization at home and in the community.
I agree to treat BBehavior staff with respect and maintain professional, courteous communication at all times.
I understand that services may be paused, rescheduled, or discontinued if required documentation is missing, authorizations expire, safety concerns arise, or policies are not followed.
I understand that ABA services are individualized and outcomes vary based on each child's skills, needs, consistency, and family participation.
I understand that fees, copays, deductibles, and non-covered services are my responsibility as outlined in the Financial Policy.
I understand that BBehavior reserves the right to update policies and procedures as needed and will communicate any changes to families.

I have read and agree to the terms of this Parent / Guardian Agreement.

4. Release of Information Authorization

Authorization to Request, Receive, and Exchange Information

I authorize BBehavior to request, receive, share, and exchange information as needed for my child's care, treatment planning. insurance authorization, coordination of services, and continuity of care.

Information May Include

Diagnosis, treatment recommendations, assessment results, progress summaries, behavior plans, therapy notes, attendance information, insurance information, medical records, school reports, IEPs, evaluation reports, referral documenta, billing information, and any other information relevant to my child's care and services.

This authorization is voluntary.
I may refuse to sign this authorization. However, if I do not sign, it may affect BBehavior's ability to obtain or share information necessary for my child's care.
I may revoke this authorization at any time by providing written notice to BBehavior. Revocation will not apply to information that has already been released based on this authorization. This authorization will remain in effect for 12 months from the date signed below, unless revoked earlier in writing.

I authorize BBehavior to exchange information as needed for my child's care and services as described above.

5. Authorization for Pick-Up & Release

Your child's safety is our top priority. Please read the following information carefully and acknowledge below.

I authorize BBehavior to release my child only to the parent, legal guardian, or individuals listed below as authorized pick-up persons.
Authorized individuals may be required to show valid photo identification before my child is released.
I agree to provide BBehavior with updated information if authorized pick-up persons change at any time.
If there are custody orders, court restrictions, protective orders, or individuals who are not permitted to pick up my child, I must provide written notice and supporting legal documentation to BBehavior.
I understand that BBehavior may refuse release of my child if staff cannot verify the identity or authorization of the person attempting to pick up my child.
I agree to notify BBehavior immediately if there is any change in custody, guardianship, or any legal restriction that may affect pick-up or release.

Authorized Pick-Up Persons

Please list all individuals (other than parent/legal guardian) who are authorized to pick up your child. Add as many as needed.

Full Name

Relationship to Child

Phone Number

I authorize BBehavior to release my child only to approved individuals listed above and agree to the terms explained.

6. Telehealth Consent (If Applicable)

Consent for Telehealth Services

Please read the following information carefully. By signing below, you consent to participate in telehealth services with BBehavior when appropriate and approved.

Some services may be provided through telehealth (video or audio) when it is clinically appropriate and approved by the treatment team.
Telehealth services may include video meetings, phone calls, parent training, caregiver coaching, treatment planning, consultations, supervision, assessment discussions, and other related services.
Telehealth may have limitations, including technology problems, privacy risks, and a reduced ability to observe certain behaviors directly.
I will participate in telehealth sessions from a private, quiet, and safe location where possible, I will ensure my child is in an environment where they can participate safely and without distractions.
BBehavior will use a secure, HIPAA-compliant platform and take reasonable steps to protect privacy and confidentiality during telehealth services.
I understand that I am responsible for having the necessary technology and internet connection to participate in telehealth sessions.
I understand that I may withdraw consent for telehealth at any time by providing a written request. Withdrawing consent may impact service delivery and scheduling.
I consent to telehealth services when clinically appropriate and approved by BBehavior.

I consent to telehealth services when clinically appropriate and approved by BBehavior.

7. Attendance Policy Acknowledgment

Our Commitment to Consistent Care

Consistent attendance is essential for your child's progress in ABA therapy. Please read our attendance policy carefully and acknowledge below.

Consistent attendance is important for skill acquisition, behavior progress, and overall treatment success.
I agree to make reasonable efforts to ensure my child attends all scheduled ABA therapy sessions.
I understand that I must notify BBehavior as soon as possible if my child is unable to attend a scheduled session.
I understand that repeated absences, late arrivals, early pickups, or missed sessions may impact my child's progress and interfere with treatment goals, staff scheduling, and insurance authorization.
I understand that BBehavior may review attendance concerns with our family and may adjust the service schedule if attendance issues continue.
I understand that insurance companies require consistent attendance and may reduce or deny authorization if attendance is poor.
I understand that if my child is sick, hospitalized, traveling, or unable to safely participate, I must inform BBehavior as soon as possible.
I understand that sessions canceled with insufficient notice may be considered billable as outlined in our Cancellation Policy.

I have read and understand BBehavior's Attendance Policy and agree to follow the guidelines outlined above.

8. Cancellation Policy Acknowledgment

Our Commitment to Respectful Scheduling

We understand that plans can change. Please read our cancellation policy carefully and acknowledge below.

I understand that BBehavior requires advance notice when a scheduled session must be cancelled.
I agree to notify BBehavior as early as possible if my child cannot attend a scheduled session.
I understand that frequent cancellations or late notices may impact my child's progress, staff scheduling, service availability, and insurance authorization.
I understand that BBehavior may request a meeting with our family if cancellations become frequent or interfere with treatment.
I understand that sessions may be rescheduled when possible, but makeup sessions are not always guaranteed.
I understand that cancellations with less than the required notice may be considered billable as outlined below.
I understand that BBehavior may update cancellation procedures as needed and will communicate any changes to families.
I understand that I am responsible for reviewing the latest cancellation policy and contacting the office if I have any questions.

I have read and understand BBehavior's Cancellation Policy and agree to follow the guidelines outlined above.

9. Custody & Legal Authority

This information helps us ensure we are following legal requirements and can communicate effectively with the appropriate individuals regarding your child's care.

Do both parents/guardians have legal custody?

If no, please explain:

Who is authorized to make treatment decisions for your child?

Are there any court orders or legal restrictions we should be aware of?

If yes, please describe:

I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that I must notify BBehavior immediately if there are any changes.

10. Safety & Incident Acknowledgement (Protection)

Your child's safety and well-being are our top priority. Please read the following information carefully and acknowledge your understanding.

Would you like to share any specific safety considerations or concerns?

I understand that ABA therapy may involve challenging behaviors such as aggression, self-injury, elopement, property destruction, or other behaviors that may pose a risk to my child or others.
I acknowledge that BBehavior will use appropriate safety and de-escalation strategies to protect my child and others.
I agree to cooperate with all safety procedures and follow the guidance provided by the therapy team.
I understand that if my child poses an immediate risk of harm to self or others, appropriate protective actions may be taken, which may include emergency interventions.
I will inform BBehavior of any changes in my child's medical, behavioral, or safety-related needs. I understand that any concerns about safety or incidents will be communicated with me promptly.

I have read and understand BBehavior's Safety & Incident Policies and agree to follow the guidelines outlined above.

Parent / Guardian Full Name *

Date *

Signature

Financial Information

Help us understand your financial preferences and how you would like to handle payments.

Who is financially responsible for this account?

Relationship to Child

How will you be paying for services?

Do you have out-of-pocket cost?

How would you like to receive statements?

Email for Statements

Billing Contact Name (If different)

Billing Phone Number

Preferred Billing Method

Communication Preferences

Let us know how you prefer to receive information and updates.

Preferred Language

How would you prefer to be contacted? (Select all that apply)

Phone Call Text Message Email Mail

Best time to contact you?

Preferred Contact Number

How would you like to receive reminders? (Select all that apply)

Phone Call Text Message Email Mail

Family Information

Primary Caregiver Full Name

Relationship to Child

Phone Number

Email Address

Marital Status

Preferred Pronouns (Optional)

Other Household Members (Please list all individuals who live in the home)

Language(s) Spoken at Home

Who has legal decision making for your child?

Child's Development & History

Was your child born full-term?

Were there any complications during pregnancy or delivery?

If yes, please describe (Optional)

Has your child had any major illnesses, injuries, or surgeries?

If yes, please describe (Optional)

Does your child take any medications?

If yes, please list all diagnoses

Has your child received any therapies or early intervention services in the past?

If yes, please list services received

Notes or Additional Information (Optional)

Upload Required Documents

Insurance Card (Front & Back)

Photo ID (Parent / Guardian)

Referral / Prescription (If applicable)

IEP / Evaluation Report (If applicable)

Previous Therapy Records (If applicable)

Digital Signature

By signing below, I certify that the information provided in this intake form is true, accurate, and complete to the best of my knowledge. I understand that any false information may delay or affect services.

Full Name

Signature

Date Signed