ABA Program Intake Form

For services provided by Rising Development, LLC.

Thank you for selecting Rising Development, LLC to help you meet the needs of your child and
family. We are proud to have your trust in us.

This 7 page packet of information will help inform you about Rising Development policies and
procedures, and help us be prepared for your intake appointment. We understand some of these
forms may be challenging and time consuming, but the more information we have, the better
Rising Development is able to assist you and your family. If at any time in the process you have
any questions, please reach out.

I look forward to meeting you and your child.

Monica Bernal MS BCBA

Rising Development LLC
965 300 2345
risingdevelopment.fl@gmail.com

Behavior Assessment

Top 3 goals for your child to achieve in the next 6 to 12 months.

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Is your child currently able to sit at a table or on the floor and do simple taste with an adult?
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For how long?

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Please list any problem behaviors that your child displayed and you are concerned about (crying,
biting, kicking, self injuring, property destruction, ect)
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Please estimate the number of times these behaviors happen and what you think might cause the
behaviors (ex, 100 times a day due to clothing discomforts, 10 times a week due to a schedule
change).
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Describe what strategies you have tried to decrease behavior and if they were successful or not.
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What are your child’s preferences and dislikes?

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Any special needs that may arise during treatment?
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Services
This document contains important information about Rising Development LLC’s applied behavior
analysis (ABA) professional services and practice policies. When you sign this document, it will
represent an agreement between you and Rising Development LLC to provide ABA services. You,
the consumer, reserve the right to withdraw at any time from these services. Please feel free to
contact Rising Development LLC with any questions or concerns about Rising Development
LLC’s ABA Services at any time.

General Treatment Information

Rising Development LLC abides by the Behavior Analyst Certification Board Guidelines for Responsible
Conduct.

Admission into ABA services will be available to children, adolescents, and adults with or without
a diagnosis based on the need/desire to modify established behaviors. Certain provisions may
apply in regard to diagnosis if someone is seeking funding for the service through a third party,
such as private insurance or Medicaid.

Services will focus on the development and implementation of a functional behavior assessment
and an ABA treatment plan. ABA services will be provided by a Board Certified Behavior Analyst
(BCBA), or highly trained Behavior Technician under the supervision of a BCBA. These services
are based on the client’s current level of individualized needs. The treatment plan will structure
antecedent and consequence based strategies that are skill based, functionally equivalent, and
non-aversive.

In addition to direct ABA treatment, ABA services also include training and ongoing consultation in
the principles of applied behavior analysis as they pertain to the client’s treatment plan with
family, educators, and any related service providers as requested by the family.

When needed, Rising Development LLC will provide the client/family with contact information for
other professionals who may be better able to assist with the needs of the client if Rising
Development LLC is unable to meet specific treatment needs. (e.g., Speech Pathologist)
 Company Policies
Assessment, Preparation, and Participation
It is important for any individual to be able to perform their best during an assessment. Please let
the Rising Development LLC know of any illness or changes in medication or diet that may
necessitate an assessment to be re-scheduled. Rising Development LLC believes in non-
aversive, trauma-informed care using an integrated treatment approach to create a positive
learning experience for any individual.

An initial assessment of 2-3 hours may be conducted in order to make recommendations, but the
complete assessment process may take 8-10 total observation hours, possibly longer, depending
on the assessment needed.

Appointments
Rising Development LLC’s ABA staff is committed to providing consistent, reliable service as
scheduled and agreed upon by the client/family. A monthly or weekly schedule of service will be
worked out between the client/family and Rising Development LLC staff assigned to the case.
This schedule will match a proposed preliminary set of hours for ABA services within the initial
treatment plan, taking into consideration medical necessity and results of the behavioral
assessment.

Rising Development LLC understands that circumstances, such as illness or family emergency,
may arise which necessitate the occasional cancellation of appointments. Rising Development
LLC asks that you attempt to give at least 12 hours of notice when canceling or rescheduling an
appointment.

To avoid any misunderstanding, Rising Development LLC’s policy is for a client or family to
contact the assigned BCBA directly to cancel or re-schedule session(s). Excessive cancellations
by a client/family may result in termination of services, as consistency of the delivery of services
as proposed in a treatment plan is critical.

Should a larger or more long lasting change be requested (for example, if you are going out of
town for a week of vacation) please give at least 2 weeks’ notice to ensure the best chance that
we will be able to accommodate the change.

Communication
Rising Development LLC is committed to responding to any questions or comments regarding ABA
Services in a timely manner. The Behavior Analyst and Behavior Technicians are committed to providing the
best quality service to clients, which includes timely, professional communication. The clients will be
provided with the telephone numbers and email addresses of those individuals involved in direct treatment
service and planning. More detailed inquiries (non-case related) and referrals for ABA service should be
directed to the Analyst.

Rising Development LLC does not offer on-call coverage for ABA services and programs on a 24-hour basis.
Clients may contact their ABA Program office with questions or comments by telephone or email.

Family Involvement

A preliminary treatment plan meeting will be scheduled with the client and ABA professionals.
This meeting is to review the proposed service type(s), treatment plan goals and objectives,
recommended duration of treatment, and a discharge plan for the client.

The contents of both the assessment and treatment plan will be explained to the client and/or
family. Rising Development LLC staff will willingly answer any related questions about the
assessment or proposed service. Rising Development LLC understands that this information is
confidential, and will abide by established confidentiality policies and procedures. The family is
always invited and encouraged to reach out with questions or concerns.

A caregiver (an adult 18 or over) is required to be present at all times when therapy is occurring. Additionally,
parent/caregiver participation is an expectation of service. Participation may include periodic team meetings,
data collection, and implementation or involvement in the implementation of recommended strategies. If
there is lack of caregiver involvement, Rising Development LLC reserves the right to reconsider the
appropriateness of service.

Upon discharge, recommendations will be provided as a way to support continued progress or

address persisting concerns.

Wellness
In order to promote health and wellbeing to our staff and clients, Rising Development LLC
operates under a “wellness policy” where sessions will not be conducted if either therapist or
client displays any of the following symptoms:
• ● Fever: Temperature of 100.0 or higher. Must be free of fever (any
 temperature above 98.6 degrees) for at least 24 hours without the use of fever reducing
medication. The same policy applies if your child develops a fever at home. They must be
fever free (any temperature above 98.6 degrees) for at least 24 hours without the use of
fever reducing medication.
• ● Vomiting: Must symptom free with no vomiting for at least 24 hours.
• ● Diarrhea: Three or more occurrences during a 24 hour period qualifies as
a need to reschedule. Must be symptom free for at least 24 hours before returning to
work/ school.
• ● Any other contagious illness (rash, conjunctivitis etc.) will be evaluated
on a case by case basis
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• Treatment Understanding
• ______ I consent for my child to receive the assessment and treatment services
provided by Rising Development LLC. I understand that all services are directed by a Board
Certified Behavior Analyst (BCBA). The BCBA supervises behavior therapists who administer a
treatment plan authored by the BCBA.

• ______ I understand that all services provided by Rising Development LLC are
confidential. Rising Development LLC is required to obtain my informed written consent before
releasing any information except where required by legislation or directed by the courts.
Examples of such exceptions may include but is not limited to reporting suspicion of child abuse
or a child in need of protection, informing someone in a position of authority if a client is in
imminent danger of harming themselves or others, or providing information as directed by the
courts through subpoena, search warrant, or other legal order.
•
• ______ I have been informed that the assessment and treatment services are
based on the principles of Applied Behavior Analysis and positive behavior modification
techniques. I understand that the goal of services is to help my child function as independently
as possible within the home, school, and community settings.
•
• _______I accept that my child will be rewarded (e.g., with food, praise, hugs, or
their preferred toys or activities) for appropriate, adaptive behaviors such as language production
or social interactions.
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 • _______I understand that when my child engages in inappropriate behaviors,
different interventions could be used, such as:
• • Redirecting attention to the task,
• • Ignoring inappropriate behaviors,
• • Rewarding alternative, appropriate behaviors,
• • Using physical guidance to help him/her respond to a command (e.g., helping
him/her to sit on a chair).
•
• ______ In the case that routinely used techniques, such as those listed above,
are not effective in reducing inappropriate behaviors, the behavioral specialist will meet with the
supervising Board Certified Behavior Analyst to discuss other possibilities for intervention. If any
intrusive intervention is recommended and approved, I understand that I will sign a written
consent form prior to any administration of these procedures.
•
• ________ In order to monitor my child’s learning throughout the program,
behavior technicians/ BCBA will complete specific data collection forms. I understand that the
services provided will rely heavily on the collection of data and that any data collected is
confidential and will be accessible only by authorized staff of Rising Development LLC.
•
• _________I understand that the possible benefits of our participation in this
program are:
• • My child’s mental age, social, and adaptive functioning may improve
• • I may become a more effective teacher for my child than I am now
•
• _________ I understand that although the treatment provided is intended to be
beneficial and has helped children like mine in the past, participation may involve some of the
following risks or discomforts for my child:
• • My child may present some behavior problems during or after therapy
• Hours
• • My child may experience some distress (e.g., crying) when the behavior
• specialists are teaching new skills such as sitting on the chair or when working
with a new therapist.
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• Payment Understanding
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• ________ I understand that Rising Development LLC will assist me in receiving any
insurance benefits to which I am entitled, however, I acknowledge that ultimately I will be responsible for the
payment of fees to Rising Development LLC, not the insurance company. I understand it is my responsibility
to read my insurance coverage booklet and to contact my plan administrator should I have any questions. If
it is necessary to clear confusion, Rising Development LLC will be available to contact the insurance
company on my behalf.
•
• ________ I am aware that Rising Development LLC may be required to provide
information on my child’s services to my insurance company and that the information required may include
personal information. I understand that Rising Development LLC will make every effort to release only the
minimum information about my child that is necessary for the purpose requested. I understand that once this
information is provided to the insurance company, Rising Development LLC will have no control over it or
how it is used. I understand that, upon request, Rising Development LLC will provide me with a copy of the
information provided to the insurance company.
•
• ________By signing this consent form, I agree that Rising Development LLC can provide
any requested information about my child and his/her assessment and treatment services to my insurance
company.
•
• ________I agree to work with Rising Development LLC to review my insurance coverage
and their treatment recommendations to determine goals for treatment with the intention of maximizing
services with the resources available.
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• ________I understand that I am responsible for all copays, co-insurances and deductibles
as dictated by my insurance plan. I agree to furnish these payments in a weekly manner unless otherwise
discussed and documented in writing.
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• Consent
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• Your signature below indicates that you have received and read the information in this
document. Consent by all parents/legal guardians is required prior to the implementation of ABA services.
• These policies have been fully explained to me and I fully and freely give my consent for
service to be implemented as proposed.
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• Client Date
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• Parent/Guardian (if applicable) Date
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• Rising Development LLC Representative Date
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