Client Intake Packet
Before completing the intake packet, please read the following Release and Consent Agreement carefully. You must agree to its terms before proceeding.
I agree to have my child evaluated/treated through BrightSpots Behavior and Learning. I understand that these services are based on an Applied Behavior Analysis (ABA) model and will be provided by a professional trained in ABA. Currently, Amy Theobald, Rhett Theobald, Alicia Roberts, and Alaina Young serve as BCBAs for BrightSpots Behavior and Learning.
I further understand that psychological diagnostic or reevaluation services are provided in collaboration with Behavioral Specialists of Louisiana and Dr. Jay Bamburg. For psychological diagnostic services, standardized diagnostic assessments will be completed by a Masters level clinician under the supervision of Dr. Jay Bamburg, who will use the standardized assessments, observation records, and appropriate medical documentation to render the diagnosis.
BrightSpots Behavior and Learning staff will receive Safety Training techniques for response to inappropriate or problematic behaviors. BrightSpots will utilize the most acceptable procedures, as outlined by their clinical judgment, to care for your child. Interventions are based on current evidence-based practices.
Physical prompting, physical redirection, physical escort and physical restraint are part of Applied Behavioral Analysis therapy when it is considered therapeutically appropriate. Appropriate precautions are taken to safeguard our clients at all times; however, there is a risk of injury involved. Physical restraint is reserved for use only when clinical judgment warrants as a result of behavioral excesses, proximity to others, and/or physical strength of a client, that threatens or endangers the health, safety and/or well-being of the client, therapist(s), third parties, or property. If restrictive procedures are used and result in some form of injury to your child, you will be notified upon pick-up the day of the incident.
I understand that BrightSpots Behavior and Learning specializes in the evaluation and treatment of problem behaviors, and that if BrightSpots is unable to meet my particular needs, I will be referred to an appropriate agency or individual. If my child or I are here with a medical-related problem, my physician will be made aware of my treatment through BrightSpots and is responsible for medical aspects of my case (i.e., medication, physical examination, etc.).
I also understand it is my responsibility to communicate any medical limitations or challenges that would make the use of ABA techniques contraindicated to the child's health. This may include but is not limited to medical conditions (asthma, seizures, etc.), physical disabilities or injuries, or a history of physical/sexual abuse.
I understand that compliance is an integral part of ABA treatment. During the treatment process, non-compliance in attendance may result in the termination of services. I understand that state laws may require that confidentiality be broken under certain circumstances, specifically, if I am judged by the Behavior Analyst to be of danger to myself and/or others, or if there is suspected child abuse.
This Release and Consent agreement will remain in effect for 13 months from the date hereof if not earlier rescinded in writing by the undersigned.
Thank you for selecting BrightSpots Behavior and Learning in helping you meet the needs of your child. We know that this process can be trying and we appreciate you having trusted us to help you with managing it.
The following questions will help inform us about your child during their intake with our therapist(s). Please feel free to add any additional information which you think may be helpful. The more information we have about your child, the better we are able to assist your family.
BrightSpots Behavior and Learning considers all information provided strictly confidential and will only release it in accordance with HIPAA guidelines as mandated by law.
If at any time you have questions, please contact us at (337) 739-8005 or [email protected].
Responsible Party / Policy Holder
Responsible Party / Policy Holder
School Services Received
Does the client or extended family have a history of the following? If yes, list the relationship.
Please indicate when your child did the following:
| Milestone | On Time | Delayed | Not Yet |
|---|
Check all your child is currently experiencing:
Pediatrician Information
If child has participated in Special Education, check all that apply:
If child participated in Special Education, how were they served?
Please describe your child's strengths and areas for growth in each skill area.
List any additional person(s), besides the legal guardians, who are authorized to pick up or drop off the child.
Emergency contacts when parents/guardians cannot be reached:
Emergency Medical Authorization: In emergencies requiring immediate medical attention, your child will be taken to the nearest medical emergency room. Your signature on the final page authorizes the responsible person at the facility to have your child transported to that hospital if the need arises.
As required by HIPAA, you may request that communications concerning your personal health information be made through confidential channels. You may also specify who else we are permitted to discuss your child's information with.
May we discuss your Child's Personal Health Information with anyone else who is not a legal guardian?
Please read each policy carefully, then initial / check to acknowledge your understanding.
If you are more than 15 minutes late for any appointment (including the intake) you will not be seen that day.
Once services begin, your child must maintain 80% of scheduled therapy attendance or they will be discharged and referred to another provider.
We require 24-hour notice for missed sessions when possible. The office can be reached at (337) 739-8005. Please inform the office before 8:45 am if the client will miss a session due to illness.
Excused absences: illness or family emergency when the family contacts BrightSpots within the designated time.
Unexcused absences: no contact, or contact without valid reason before 8:45 am. After the 2nd unexcused absence, the family will be placed in probationary status. After the 3rd unexcused absence, services will be terminated.
Sessions are to be cancelled when:
Your insurance is not designed to pay the entire cost of treatment. The remaining balance not covered by your insurance carrier will be your responsibility.
IMPORTANT: THE FINANCIAL OBLIGATION FOR THESE SERVICES IS YOUR RESPONSIBILITY. If a payment by check is returned, you will be charged a $35.00 service fee.
Rates: Individualized assessments $1,200.00. 1:1 therapy $50.00â$90.00/hour depending on therapist credentials. Parent consultations $50.00 per 30 minutes.
BrightSpots will not turn any child away due to potty training difficulties. However, parents must actively work on potty training at home. It is required that parents provide pull-ups/underwear and 3 extra changes of clothes at all times while potty training.
Clothing that can be difficult: tight fitting, overalls, pants with belts, one-piece outfits.
Initial next to each policy to confirm:
I hereby authorize and consent for the release of my child's medical records and confidential information to BrightSpots Behavior and Learning (512 Thoroughbred Dr, Lafayette, LA 70507 | (337) 739-8005), for the purpose of coordination of care.
By signing below, you confirm that all information provided is accurate and that you have read and agree to all BrightSpots policies.
Thank you for completing your intake packet for . The BrightSpots team will review your information and be in touch soon.
Questions? Call us at (337) 739-8005 or email [email protected]