Parental Verification For Receipt Of Behavioral Services Page 2

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State of California--Health and Human Services Agency

Department of Developmental Services

PARENTAL VERIFICATION FOR RECEIPT OF BEHAVIORAL SERVICES

DS 5862 (6/2011)

Page 2 of 2

Instructions to the Vendor: Section

4686.31

of the Welfare and Institutions Code requires any vendor who provides Behavioral Services as

specified in Title 17 of the California Code of Regulations* to submit a completed verification form to the regional center for services provided to

consumers under the age of 18 years who reside in the family home. The vendor must submit the completed verifications to the regional center

with the invoices for the services provided. If the parents or legally appointed guardians of a minor consumer do not submit a verification of

services to the vendor, the vendor shall contact the regional center. Failure of the parents or legally appointed guardians of a minor consumer

to submit a verification of services to the vendor shall not be a basis for terminating or changing behavioral services to the minor consumer.

*This applies to the following Service Codes: 612-Behavior Analyst, 613-Associate Behavior Analyst, 615-Behavior Management

Assistant, 616-Behavior Technician-Paraprofessional, 620-Behavior Management Consultant, 625-Counseling Services, 680-Tutor,

017-Crisis Team-Evaluation and Behavioral Intervention Training, 025-Tutor Services – Group, 048-Client/Parent Support Behavior

Intervention Training, and 077-Parent-Coordinated Home Based Behavior Intervention Program for Autistic Children.

Instructions to the Parents or Legally Appointed Guardians: Please sign, date, and submit this form to your vendor within 30 days from

the time the services were provided. If you are unable to sign the form, please contact your regional center service coordinator/case manager

as soon as possible.

If you have any questions, please feel free to contact your regional center service coordinator/case manager.

I verify that the Behavioral Services provided to the consumer listed on this form were provided at the location, dates, and times as shown and are true, correct, and

complete.

______________________________________

Name of Parent/Legally Appointed Guardian

___________________________________________________

_______________________

Parent or Legally Appointed Guardian Signature

Date