Inhome Aba Program Intake Packet (Page 14 of 27) in pdf

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Teaching Skills for Success

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Go b ack a nd r ate t he T HREE M OST e ffective s trategies. T hat i s, p lace a 1 b y t he m ost e ffective, a 2 b y t he

next m ost e ffective, a nd a 3 b y t he t hird m ost e ffective. P lease c ircle t he L EAST e ffective. P lease r ate w hat

percentage o f d iscipline i s h andled b y e ach o f t he f ollowing:

Father:_____% M other:____% O ther: _ ____% ( Please S pecify:)______________________________

GENERAL I NFORMATION:

Please l ist t he f ive t hings y ou w ould l ike f or y our c hild t o d o m ore o f a nd l ess o f i n o rder o f p riority t o y ou.

For e xample, i nstead o f s aying, “ I w ant m y c hild t o b e m ore r esponsible,” t ranslate t hat i nto a ctual

behaviors s uch a s d o h ousehold c hores, c are f or b rothers a nd s ister, e tc.

L ike C hild t o d o M ore O ften L ike C hild t o d o L ess O ften

1. _ __________________________ _ ____________________________

2. _ __________________________ _ ____________________________

3. _ __________________________ _ ____________________________

4. _ __________________________ _ ____________________________

5. _ __________________________ _ ____________________________

INFORMED C ONSENT F OR B EHAVIORAL S ERVICES

I h ereby v oluntarily a pply f or a nd c onsent t o s ervices b y B ehavior M atters L LC. T his c onsent a pplies t o

myself, w ard, o r c lient n amed b elow. S ince I h ave t he r ight t o r efuse s ervices a t a ny t ime, I u nderstand a nd

agree t hat m y c ontinued p articipation i mplies v oluntary i nformed c onsent. I u nderstand a nd a gree t hat

my d isclosures a nd c ommunications a re c onsidered p rivileged a nd c onfidential e xcept t o t he e xtent t hat I

authorize a r elease o f i nformation, o r u nder c ertain o ther c onditions l isted b elow: ( 1) w here a buse o r

harmful n eglect o r c hildren, t he e lderly, o r d isabled o r i ncompetent i ndividual i s k nown o r r easonably

suspected: ( 2) w here s uch i nformation i s n ecessary f or t he c ompany t o p ursue p ayment f or s ervices

rendered; ( 3) w here a n i mmediate t hreat o f p hysical v iolence a gainst a r eadily i dentifiable v ictim i s

disclosed t o t he t herapist; ( 4)where t he c lient i s e xamined p ursuant t o a c ourt o rder. I h ole B ehavior

Matters L LC h armless f or r eleasing i nformation u nder t he a bove c onditions.

____________________________________ _ ____________________________

Signature D ate

____________________________________ _ _____________________________

Printed N ame N ame o f C lient

Inhome Aba Program Intake Packet Page 14