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  • This Agreement contains important information about Early Autism Services, LLC’s (“EAS”) Services and business policies and procedures. Please read it carefully. Additional information regarding EAS’s Services and business policies and procedures may be found at EAS’s website:
  • 1.) Applied Behavior Analysis Services

    Applied Behavior Analysis (“ABA”) Services consist of providing care to EAS’s patients, which includes, but is not limited to, individualized ABA programs; parent education; toilet training; sleep consultations; and feeding services. Each ABA program varies and is designed to fit each individualized Child’s needs. In addition, the Services provided by EAS calls for a very active effort on the parent(s)’ part. In order for the ABA programs to be most successful, the parent(s) must play an active role. The first week of Services will require the parent to shadow either the Board Certified Behavior Analyst (“Consultant”) or Behavior Technician (“Therapist”), who is assigned to your Child. During this time, EAS can both decide if there is a mismatch between the assigned Consultant and/or therapist and your Child. In addition, during this time period, the Consultant and Therapist will become familiar with your Child’s needs and schedule. Data will be collected throughout the entire session. Data will be documented in the Program Book. The collection of data is mandatory for the Services provided by EAS. If you have questions about EAS’s procedures in collecting data, please discuss with the Consultant and/or Therapist.
  • 2.) ABA Therapy Sessions

    ABA Therapy Sessions shall take place at the Child’s home. A parent and/or designated guardian shall be present at all times. If a parent and/or guardian is unable to be present for any length of time, please notify the Consultant and/or Therapist so the appropriate arrangements can be made. EAS and the parent will determine the length of the ABA Therapy Sessions in advance. The required minimum amount of time each ABA Therapy Session length is scheduled for is 2 hours. Any changes to the ABA Therapy Sessions shall be communicated immediately to the Consultant assigned to the Child’s care, which includes the session’s place of location, appointment time, or appointment length. Please note that the Therapists do not have the authority to make any changes to the ABA Therapy Session schedules.
  • 3.) Rescheduling ABA Therapy Sessions

    When you need to reschedule any ABA Therapy Sessions, please contact EAS and/or the Consultant at least one week in advance.
  • 4.) Out of Pocket Costs for Cancelled Appointments

    If you need to cancel a scheduled ABA Therapy Session appointment, you will be responsible for the appointment fee unless you reschedule your appointment (as described earlier), or provide at least 24-hour advance notice. If you need to change the place of location or the appointment time of the scheduled ABA Therapy Session, you must provide at least 24 hours advance notice. In addition, you will be charged for cancelled team meetings, unless you provide EAS one-month prior notice. By signing this Informed Consent Agreement, you have agreed to pay for any missed and/or late cancelled appointments that have not been rescheduled.
  • 5.) Fees for Services; Court Related Services and Insurance

    a. Fees EAS’ fees for its Services are as follows (with exception of contracted rates with certain insurance companies): Consultant $90.00 per hour; and Behavior Technician: $35 per hour. Charges will be broken down into 15-minute intervals for periods of work of less than one hour. All fee arrangements will be made in advance and prior to the commencement of the Services depending upon the needs of your Child. If other services are required by EAS, which include, but are not limited to, writing reports, telephone conversations lasting longer than 15 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries (for insurance purposes), fees for these services will discussed at the time they are requested. b. Court Related Services In the event you become involved in legal proceedings (i.e. Dissolution of Marriage, Child Custody, etc.) that require EAS’s participation and if EAS’s fee is not paid by the attorneys, you will be charged for the time EAS spends responding to legal matters. Because of the difficulty of legal involvement, EAS charges $110.00 per hour for court related services. Court related services include talking with attorneys, preparing documents, depositions, travel time, preparation for testimony and court appearances. Charges for court related services are not covered by insurance. c. Insurance Contracts and Discounted Fees If EAS has a contract with your insurance company, EAS will bill at the contracted rate. However, you will be responsible for any deductibles, co- payments or coinsurance charges. d. Insurance Reimbursement and Managed Care If you are seeking reimbursement for services under your health insurance policy, you will be required to sign a consent, giving EAS permission to bill your insurance and release whatever information your insurance company requires to process the claims we submit. At a minimum, they will require a clinical diagnosis (see Appendix A and B for more details on insurance reimbursement and managed care and consent for EAS to bill primary and secondary insurance directly). i. Information released to your Managed Health Care Plan "Managed Health Care" plans such as HMOs, POSs, and PPOs, typically require that they authorize mental health treatment (therapy) before providing reimbursement. They will require your clinical diagnosis, and often require additional clinical information such as treatment plans, updates on treatment progress, and even copies of your Clinical Record. To use your Managed Care Insurance you will have to sign a release giving your therapist permission to release this information to your Managed Care Company. ii. Managed Care Limits on Treatment Managed Care Plans may limit your mental health coverage to time limited short-term treatment approaches. In addition, insurance plans may limit coverage to a certain dollar amount or number of sessions per year. Please check your insurance carefully so you are clear on the number of sessions/coverage available. i. A payment plan does not qualify for the discount.
  • 6.) Contacting EAS

    If you have any questions or concerns about the quality of services, personnel (including Consultants or Therapists), the program, or of the agency in general during the time of your services, please to contact either Mareiko Au or Vincent Scarlata at
  • 7.) Professional Records

    The laws and standards of EAS’s profession require that it keep clinical treatment records. You are entitled to receive a copy of your Child’s records if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your Child’s records, EAS recommends that you review them in a Consultant’s or Therapist’s presence so that the parties can discuss the contents. Patients will be charged an appropriate fee for any professional time spent in responding to information requests. You will be charged a fee of $1.00 a page for copying your Child’s clinical treatment records.
  • 8.) Limits on Confidentiality

    The law protects the privacy of all communications between a patient and a therapist. In most situations, your therapist can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA and/or Illinois law. However, in the following situations, no authorization is required (see Appendix C for details): a. Sharing Information Among EAS Staff Consultants and/or Therapists share clinical information as part of case consultation, coverage for vacation or illness, and quality assurance review. Also, administrative staff has access to records for billing purposes. Information is not shared when contraindicated. When records are transported, they are kept in a sealed envelope and not kept outside of the home or EAS’s office address for more than 24 hours. b. Court orders, Governmental Requirements and Legal Proceedings EAS may be ordered by a Court of competent jurisdiction or any other governmental agency to release confidential information. c. Legally Mandated Instances for Breaking Confidentiality Instances that legally mandated EAS for breaking confidentiality include: suspicion of child abuse; suspicion of elder abuse; imminent threat of harm to others; and imminent danger/serious risk of harm to self.
  • Consent to Receive Services/Therapy

  • Email Communications

    Please read the information below and confirm if you authorize Early Autism Services to communicate through email. If you authorize EAS to communicate via email, please provide your current email address at the end of this agreement. I acknowledge the that I have read and fully understand this consent form. I understand the risks of communicating by email, in particular the privacy risks explained in this form. I understand that Early Autism Services cannot guarantee that security and confidentiality of email communication. Early Autism Services will not be responsible for messages that are not received or delivered due to technical failure. I understand that I may also communicate with Early Autism Services by calling my assigned BCBA or during a scheduled appointment. I understand that phone calls or a scheduled appointment should be made for any urgent matter or communicating changes with my personal information. I understand that I may revoke this consent at any time by submitting a written notice at Early Autism Services, 5877 Livernois St. Suite 104, Troy, MI 48098. I understand Early Autism Services may stop using email as a means of communication upon written request.