INTAKE FORM | Shine Aba Solutions

Client Intake Form

Consents and Authorizations

Consent for Treatment:
I authorize Shine BA Solutions to treat my child with ABA treatment therapy.

Consent for Telehealth Services and Treatment:
I acknowledge that prior to delivery of services, I have received, read, and agree to Shine ABA Solutions Telehealth agreement.

10 Hour Minimum Policy:
I acknowledge that I have received, have read, and agree to Shine ABA Solutions’ 10-hour policy. The policy has been fully explained to me and I fully and freely give my consent for services to be implemented as proposed.

Late & Cancellation Policy:
I acknowledge that I have received, have read, and agree to Shine ABA Solutions’ cancellation policy. The policy has been fully explained to me and I agree to the terms and conditions.

Privacy Policy Consent:
By signing below, I acknowledge that I received a copy of the Notice of Privacy Practices for Shine ABA Solutions prior to delivery of services.

Authorization to Release Health Care Policy Handbook:
I hereby authorize Shine ABA Solutions to obtain copies with the detailed information of the healthcare policy handbook of my insurance as indicated above, and the cost factors of services from these health plan(s).

Authorization to Release Information:
I authorize Shine ABA Solutions to release information requested by my insurance company to complete my claim.

Parent/Caregiver Handbook Acknowledgement:
I have received, have read, and agree to adhere to the Parent/Caregiver Handbook. I agree to abide by the Shine ABA Solutions policies set forth in this handbook. I have agreed to the appropriate patient responsibilities/conduct guidelines, provide permission for Shine ABA Solutions to conduct treatment on private property, and will not hold CBS liable for property damage. These policies have been fully explained to me and I fully and freely give my consent for services to be implemented as proposed.

Authorization to Pay Claims to CBS:
I authorize payment from the insurance company to be paid directly to Shine ABA Soutions. This allows Shine ABA Soutions to file claims on my behalf.

Billing Policy:
I acknowledge that I received a copy of the Compassionate Billing Policy for Shine ABA Soutions.

Cost Sharing Policy:

I acknowledge that prior to delivery of services, my insurance benefits and the cost-sharing details were discussed with me. As my child is covered by a commercial payor and a Medicaid payor, I give my consent to Shine ABA Soutions to bill my commercial insurance and I will be responsible for any copays, deductibles, co-insurance under that plan. I will also be respoible for any claims that will not be paid by my commercial payor.

Assignment of Benefits and Claims and Patient Financial Responsibility:
I acknowledge that I received a copy of the Assignment of Benefits and Patient Financial Responsibility for Shine ABA Soutions and I accept full responsibility for my account with Shine ABA Soutions.

ASD Resource List:
I certify that I received the Shine ABA Solutions resource list for ASD.

Parent-Provider Consent for Accompaniment Outside the Home:
I authorize the ABA paraprofessional/BTs and/or BCBA, approved employee(s) with Shine ABA Soutions, to accompany my child(ren) outside the home for the duration of ABA therapy provision. Examples of this include, but are not limited to, trips to the park, visits to a local store, a walk, etc.

Patient Information

Patient First name

Patient Middle name

Patient SSN

Patient Last name

Patient Birthday

Legal Guardian Information

Guardian 1

First name

Middle name

Last name

Address Same as Patient?

Yes

Phone

Guardian 1

First name

Middle name

Last name

Address Same as Patient?

Yes

Phone

Patient Insurance Info

It is the client’s responsibility to reveal all insurances they have at the time of intake, as well as keep Shine ABA Solutions updated of changes in insurance along the course of treatment. In the event a member fails to inform of additional payers which may be liable for payment, it will be the member’s responsibility to pay for such, including cost-sharing applied by primary payer.

Insurance Member ID

Policy Holder Name

Group ID

Plan Effective Date

Employer Information

Policy Holder SSN

Policy Holder DOB

Other Insurance Coverage?

Yes

When there is a dual coverage, Mediciad and Medicaid Managed Care policies are considered as a secondary plan

Insurance Member ID

Copy of Insurance Cards

Upload File

In the case that I have missed my monthly premium payment and/or there has been a change in my coverage, I agree that I’ll be responsible to notify the Shine ABA Solutions team immediately and will be responsible to pay all costs for all sessions during the period of which there was a lack of insurance coverage.

Patient Primary Care Physician Information

Patient PCP Name

Patient PCP Phone

Patient PCP Email

Developmental History

Do you have a Recent Evaluation?

Yes

If Yes, please Download Evaluation

Evaluation

Upload File

If No, please Follow Up Date

Follow Up Date

Do you have a Recent IEP

Yes

If Yes, please Download IEP

IEP

Upload File

Do you have a referral for ABA dated within the last 6 months?

Yes

If Yes, please Download Referral

Prescription for ABA sevices

Upload File

If No, please Follow Up Date

Follow Up Date

What school does your child attend?

Is your child seeing any specialist?

Yes

If Yes, What type of specialist?

What previous therapy has your child received and how did he/she respond?

Please describe child’s milestone developments:

What goals would you like to address with ABA services?

Does your child receive any other services?

Yes

If Yes, Can we collaborate with the service provider?

Yes

I Yes, Please list services and providers:

What positive developments do you see in your child’s development?

What challenges do you face with your child?

What maladaptive behaviors does your child exhibit?

Is your child attending any educational day program? Please describe

Services and Availability Details

Note: In order to maintain consistency and an appropriate level of case, we require 10 hours of minimum weekly direct care provided by the Behavior Technician (also known as BT, ABA Therapist, or Paraprofessional). If a session is cancelled, please reschedule it.

The more flexible your preferred schedule is (more days, longer preferred hours), the sooner Shine ABA Solutions can find a Behavior Technician who can accommodate your schedule.

Are you open to BCBA Telehealth Services?

Yes

Hybrid

Preferred BT Gender

Male

Female

No preferences

Special Notes

Your Signature

Date Signed

By signing above, I attest that I have reviewed and give my consent/authorization as stated above.

Your First and Last Name

Patient Relationship

Mother

Father

Legal Guadian

Other

Thanks for submitting!

Client Intake Form

Consents and Authorizations

Patient Information

Legal Guardian Information

Guardian 1

Guardian 1

Patient Insurance Info

Patient Primary Care Physician Information

Developmental History

Services and Availability Details

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
Please Fill This Form

CONTACT

Client Intake Form

Consents and Authorizations

Patient Information

Legal Guardian Information

Guardian 1

Guardian 1

Patient Insurance Info

Patient Primary Care Physician Information

​​Developmental History

Services and Availability Details

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA Please Fill This Form

Developmental History

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
Please Fill This Form