Consent to Participe

1) Initial & Annual Consent to Participate

Overview of Services Blessed ABA Therapy Service. is an agency serving individuals (and their families) with disabilities and behavioral challenges across the United States. We utilize behavior analysts and behavior technicians by providing supervision to ensure adherence to our model. Our services are designed to meet the unique needs of the individuals we serve and are subject to the availability of qualified staff.  Blessed ABA Therapy Service is an individualized, research-based process that incorporates the principles of applied behavior analysis and person and family centered practices. The overarching goal is to produce lasting changes in the quality of life of the people we serve. It involves conducting a comprehensive assessment to develop interventions in collaboration with family members, educators and direct services providers and others caring for the individual. The following flowchart provides an overview of our process.

2) Expectations for Participation

To achieve the best possible outcomes for the individuals we serve, we believe it is essential to fully engage and empower families and other caretakers to carry interventions over into homes, schools, and communities. Instead of simply providing direct services, much of our work occurs in collaboration with others supporting the individual. As a partner in this process, you are agreeing to work closely with us and assume mutual responsibility for the individual's success. That means communicating with us regarding your goals, needs and challenges and taking an active role in on-going treatment.

Specifically, you agree to take an active role in treatment by:

a) Communicating with members of the individual's support team (e.g. teachers, therapists, step-parents)

b) Gathering information to track the individual's behavior and circumstances surrounding it (e.g., collect data)

c) Help us to design a behavior support plan that is feasible for you and your family/agency

d) Actively participate in the coaching sessions to practice the support plan strategies

e) Be physically present and alert for all sessions

f) Make your best effort to implement the strategies on an ongoing basis, providing the behavior analyst feedback on the plan's effectiveness to include on-going data collection g) Participate in evaluating our program by responding to caregiver surveys when administered I understand that Blessed ABA Therapy Service. staff are not permitted to babysit, provide respite care, or transportation services and that a guardian or adult designee must physically present and alert in the same area at all times. I understand that in order to provide the greatest quality of care for my loved one, Blessed ABA Therapy Service. uses multiple layers of oversight and supervision for all clients. There will be times during the course of treatment that my loved one's behavior plan and clinical notes will be reviewed by a senior member of the leadership team to certify treatment integrity. Some of this oversight is billable to a funding source and may reflect on claims, session dates, and/ or invoices.

3) Safety

Maintaining the safety of our clients and employees is critical to service delivery. For this reason, behavior analysts and behavior technicians may utilize an environmental safety checklist to identify potential risks prior to beginning services. Our behavior analysts and technicians will NOT enter or work in environments that pose significant risks.

This includes but is not limited to:

a) Settings with environmental hazards (e.g., dangerous chemicals, broken glass, unsafe structures, etc.)

b) Environments with weapons and/or firearms are not locked in a secure cabinet, containers, or room

c) Environments with individuals are using or are under the influence of narcotics and/or alcohol

d) Environments with individuals are engaging in violent, threatening, or intimidating behavior to include any type of physical, verbal, or sexual harassment. All of the previously mentioned behaviors will be reported to the local law enforcement immediately.

e) Environments where at least 1 guardian or adult designee is NOT physically present in the same area and alert at all times

4) Crisis Management

Some of the individuals that we serve face significant behavioral challenges that put themselves and/or others at risk of injury or harm. In instances such as these, the crisis will be managed using the least intrusive and most effective strategies to curtail the behavior. Blessed ABA Therapy Service recommends making every effort to avoid provoking this type of behavior unnecessarily and to respond quickly to address problems as soon as they arise (e.g., through prompting communication, presenting choices or assistance, clarifying expectations, or using redirection). However; in the event that the individual engages in behaviors that put themselves or others at risk for injury or harm, the behavior analyst may recommend reactive strategies in the behavior plan, to include state approved restraint procedures, in order to ensure the safety of the individual and/or others. As the legal guardian, you have the right to deny use of physical restraint. If the caregivers and/or staff are unable to manage the behavior safely, it is recommended to call 911 for assistance. If medical attention is required, the guardian/caregiver is responsible for providing transportation. Specific crisis management procedures will be incorporated into the individual's behavior support plan

 5) Risks and Benefits

Participating in any treatment has numerous benefits, but also certain inherent risks. For example, individuals receiving services from Blessed ABA Therapy Service may experience disruptions in typical daily routines (e.g., due to professionals entering the setting or suggesting changes in routines), stress associated with identifying problematic patterns or learning to respond differently to the individual's behavior, or frustration at delays in progress or the necessity to modify approaches periodically. Blessed ABA Therapy Service will make every effort to minimize these risks and make services optimally beneficial and enjoyable.

 6) Settings/Participants

Intervention is most effective when developed based on patterns across all settings in which there are concerns and involving support providers in those settings. Please complete the following table on the locations in which you would like the assessment and subsequent intervention to occur. Please provide the address and names of participants in each setting and check the box to indicate your consent to access these sites and individuals

7) Cancellation Policy

Regular attendance is required for our services to be effective. Irregular attendance costs both the assigned staff member and overall program time and money. It is therefore the responsibility of the individual and his or her legal guardian to attend and participate fully in all scheduled appointments. It is expected that caregivers or adult designee will be physically present and alert at all times. Exceptions will be made for client's who are over the age of 18 and legally competent if specified in their behavior support plan as a medical necessity. If you are unable to make a scheduled appointment, please contact the staff member who is assigned to see you 24 hours prior to the scheduled appointment. Canceling within 2 hours of your scheduled appointment or not showing for an appointment will be considered a “no show”. If you no show or cancel more than twice in one month, your assigned staff member will contact you to make a plan for improving attendance, such as a change in schedule. If you cannot be reached for more than 1 week or if you have at least 3 cancellations or no shows within 1 month, your services will be discontinued. If at a later date you wish to resume services, you must re-apply for services and in areas where there are waitlist, you will be placed on the waitlist from the date you re apply. Upon availability for services to begin, you must provide a written request offering a resolution of the barriers to consistent attendance prior to beginning services. Caregivers are required to notify PBS providers and cancel sessions as soon as possible if anyone in the place of service presents the following: Fever: Fever is defined as having a temperature of 100°F or higher taken under the arm, 101°F taken orally (a child needs to be fever free for a minimum of 24 hours before returning to school, that means the child is fever free without the aid of Tylenol®, or any other fever reducing substance.) Fever AND sore throat, rash, vomiting, diarrhea, earache, irritability, or confusion. Diarrhea: runny, watery, bloody stools, or 2 or more loose stools within last 4 hours. Vomiting: 2 or more times in a 24 hour period. Note: please cancel your session if your child has any of the following listed below. Breathing trouble, sore throat, swollen glands, loss of voice, hacking or continuous coughing. Frequent scratching of body or scalp, lice, rash, or any other spots that resemble childhood diseases, including ringworm. Blessed ABA Therapy Service Providers are also required to cancel any sessions they may have if they present with a fever or contagious illness. Blessed ABA Therapy Service may pause services to a client in the event it has been determined that a potential health related illness/sickness may affect the health, safety and welfare of its employees.

8) Confidentiality

Maintaining strict confidentiality of client records and information is very important to us. BLESSED ABA THERAPY Corp. will maintain records at both our corporate offices (Corporate office: 3845 Cypress Creek Parkway Suite 447, Houston TX 77068) and electronically on our BLESSED ABA THERAPY owned secured servers. Records may only be accessed by authorized personnel and will be protected via locked file cabinets and encrypted passwords on computers. No information related to an individual who is receiving services, either verbal or written, will be released to other agencies or individuals without the express written consent of the individual's legal guardian. BLESSED ABA THERAPY maintains all records for at least a 10-year period or 1 year past the age of 18, whichever is greater.

By law, however, the rules of confidentiality do not pertain under the following conditions.

1. Mandated reporters: All BLESSED ABA THERAPY Corp. staff are mandated by law to report the following to the local law enforcement office and/or the local child welfare office for investigation.

a. Suspected, reported, or observation of abuse, neglect, or harassment of any minor, disabled, or elderly person.

 b. Reports of suicidal or homicidal ideations, whether reported in person, via phone, or electronic means.

c. When a client or another individual's life is in danger or is reported to be in danger, BLESSED ABA THERAPY Corp. has the right to warn the potential victim and notify law enforcement.

d. In the event of a medical emergency, emergency personnel may be given necessary information from your medical record.

e. BLESSED ABA THERAPY Corp. staff may consult with other BLESSED ABA THERAPY Corp. staff for the purpose of case consultation, releasing only the necessary information regarding the reason for consultation.

2. Subpoenas and court orders: We are required by law to produce medical records or appear in court to answer questions regarding the individual served if we are subpoenaed or otherwise court ordered.

3. State or Department of Health Complaints: If you file a complaint against BLESSED ABA THERAPY Corp. with the State or with the Department of Health and they request medical records or other information regarding your services, we are required to release the requested information.

4. When legal documentation is provided of legal guardianship, we are required to share all records with all legal guardians at their request, regardless of if one of the guardians’ requests that we do not share the information.

5. In the event of the client's death or disability, the information may be released if the client's personal representative or the beneficiary of an insurance policy on the client's life signs a release authorizing disclosure.

6. Caregivers are required to obtain consent from the BLESSED ABA THERAPY staff when the staff member is the subject of video monitoring, and/or audio recording. Caregivers should follow their state-specific laws regarding audio recording and video monitoring.

7. To request professional credentials of your clinical staff of BLESSED ABA THERAPY, contact our Human Resources Department in writing at HR@ blessedabatherapy.com. The credentials request will be processed within 3 to 5 business days. If you choose to break confidentiality by sharing private information through conversations or an unsecured communication medium (e.g., email, telephone), BLESSED ABA THERAPY cannot be held liable for the outcome.

9) Infectious Disease

Reporting BLESSED ABA THERAPY Corp. adheres to state and federal guidelines outlined by the department of health in reporting confirmed and suspected cases of infectious disease(s). If any member of BLESSED ABA THERAPY Corp.'s team or a caregiver suspect or confirm infectious disease in an individual, they are obligated to report it to their local or regional health department. If the infectious disease suspected or confirmed is deemed a health hazard for BLESSED ABA THERAPY staff, sessions will be canceled and services put on hold until the individual is cleared to resume services by a Medical Doctor.

10) Gifts and Personal Events Policy

It is inappropriate and against ethical guidelines set forth by the BACB (http://bacb.com/ethics/) for our staff that are providing services to you and your family to accept money, gifts, food, or services from clients and/or their caregivers (i.e. dinner, cash, gift cards, gas money, tickets or admission to events, etc.). Additionally, it is against the BACB ethical guidelines for staff providing services for you and your family to attend your personal events (i.e. birthday parties, bar mitzvah's, holiday parties, etc.). For this reason we ask that your refrain from offering any of the above mentioned items or invitations to events to our staff. I understand that if I offer any of the above mentioned items or invitations to events to the staff that provide services to us, they will be required to deny all that is offered in order to abide by our ethical guidelines.

11) Caregiver Reports and Surveys

It is our priority at Blessed ABA Therapy Service. to ensure that we are providing you with the highest quality of services. In order for us to monitor this, we will be sending out Caregiver Surveys on an annual basis. Your feedback is important for us to address any areas of need so that we may continue to improve our service delivery. You will have access to view your clinical session notes and billing information on our secure Parent Portal Blessed ABA Therapy Service. This means any provider that was in the home and provided direct service to your family will be listed on the report. In addition, any provider that billed in-direct services such as plan development, protocol development, data analysis, or clinical reviews will also show on this report. This report keeps service providers accountable for services and keeps you informed regarding what was billed. If for some reason you notice a discrepancy please contact your Regional Coordinator immediately and they will work with you to correct the issue.

12) Discharge Process

BLESSED ABA THERAPY Corp. will not turn down a family for coverage nor will we discharge or discontinue treatment on the basis of race, creed, sexual orientation, or socio-economic characteristics. BLESSED ABA THERAPY Corp. reserves the right to discontinue services or discharge individuals from their services under the following conditions:

1. Individual achieves all of his/her behavior plan goals and the guardian/individual agrees that no other socially significant goals should be addressed.

2. Guardian/individual refuses to follow the mutually agreed upon treatment plan after repeated reminders and attempts to resolve barriers to implementation, to include repeated no-shows and/or cancellations.

3. Individual ages are out of coverage with funding source (regulations vary based on funding source and state).

4. Individual is not achieving the goals of treatment despite exhaustion of all known interventions, procedures, and research-based strategies.

 5. BLESSED ABA THERAPY Corp. staff become aware of circumstances (e.g., drug abuse, illegal activities, hostile or harassing behavior of caregivers) that may place them at risk to harm or injury. 6. Legal guardian or individual (if legally competent adult) decides to terminate services for any reason.

7. BLESSED ABA THERAPY Corp. is unable to provide the level of support recommended due to lack of available staff. This could be due to staff resigning, updates to the behavior plan requiring an increase in staffing, caregivers requesting a change in staff; however no other staff or available, etc. In these situations, we will do our best to provide 30 days' notice of our intent to discontinue services so that you will have sufficient time to obtain another provider.

If at any time BLESSED ABA THERAPY Corp. or the guardian/individual determines that services must be terminated, we will notify the other party immediately and establish a discharge plan to be provided to the guardian/individual. If an individual is discharged from BLESSED ABA THERAPY Corp., we will provide a list of other ABA providers, as a courtesy, to the individual and their caregiver; however this list is in no way a recommendation of specific providers. Our staff does not provide services or recommendations outside our area of expertise.

13) Rights of Our Clients 

Individuals with disabilities (and behavioral challenges) have the same rights as everyone else. BLESSED ABA THERAPY . embraces the Bill of Rights for the Developmentally Disabled and does everything in its power to uphold these rights. These rights specify that individuals and their families must be treated with dignity and that behavioral procedures must be explained in user-friendly terms. Individuals also have the right to be free from abuse, neglect, and exploitation. If you suspect that an individual is being abused, neglected, or exploited, this should be reported immediately to law enforcement or your state designated abuse hotline.

 14) Rights of Our Staff

BLESSED ABA THERAPY does not tolerate the discrimination of any staff members on the basis of race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, membership in an employee organization, retaliation, parental status, military service, or other non-merit factor. All staff members assigned to provide treatment are to be treated with dignity, compassion and respect as an individual. Failure to uphold these requirements is grounds for termination of services.

15) Grievance Procedures 

BLESSED ABA THERAPY Corp. makes every effort to meet the needs of the individuals we serve, to include being responsive to all concerns. If you are not satisfied with the services you are receiving from the staff assigned to you, please first address your concerns with the Quality Assurance Department, Theresa Wyres-Quality Assurance Director at blessedabatherapy@gmail.com. If you feel the issue cannot be resolved, please contact your funding source and/or case manager. We will investigate the concern thoroughly within 30 days and propose a solution. Grievances and their resolutions will be documented and maintained by BLESSED ABA THERAPY Corp. To file a professional practice complaint for certified Behavior Analysts and/or Registered Behavior Technicians you may contact the BACB board website: https://www.bacb.com/notice/. You have specific rights under the privacy rule. BLESSED ABA THERAPY will not retaliate against you for exercising your right to file a complaint and/or grievance.

16) Telehealth (Telemedicine) 

BLESSED ABA THERAPY Corp adheres to the guidelines established by HIPAA for the safe and secure administration of behavior analysis services through Telehealth. As with conventional behavior analysis services, all client medical records and treatment interventions are kept confidential. Electronic files, images and audio/ video tapes are protected through encrypted transmission and all video site visits are conducted through a secure analyst-to-client connection. Protocols are scrupulously followed to ensure that the privacy and confidentiality of each client is maintained.

17) Acknowledgement and Consent

I certify that I have authority to legally consent to assessment and on-going treatment, release of information, and all legal issues involving garciaclientONE,ernestoclientONE. Upon request, I will provide BLESSED ABA THERAPY Corp. with proper documentation of guardianship. If my status as legal guardian should change, I will immediately inform BLESSED ABA THERAPY Corp. and provide the name, address, and phone number of the person(s) who have assumed that role. I hereby acknowledge that I have received information on BLESSED ABA THERAPY Corp.'s participation expectations and policies regarding records release, confidentiality, payment and financial responsibility, appointment cancellation, discharge, and grievance procedures and have had the opportunity to ask questions and get clarification regarding these requirements and processes. I have received a summary of the HIPAA Privacy and Security Standards, Recipient Choice and Rights, and abuse hotline number. This consent will be updated annually. I acknowledge that accessing services through BLESSED ABA THERAPY Corp. is a choice and that I have the right discontinued services at any time without repercussion. Additionally, I acknowledge that I have the choice to change companies or request a change in any assigned staff at any point. I provide my consent for Nguyen, Stacey to participate in an assessment and on-going services through BLESSED ABA THERAPY Corp. in the settings and at the times I have indicated and that are mutually agreed upon thereafter. No promises have been made to me about the results of treatment. I agree to be physically present and alert and to participate fully in treatment. By signing below, I am acknowledging that I have read, understand, and agree to all of the terms within this document. My consent expires one year after the date below