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.

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.

When you need to reschedule any ABA Therapy Sessions, please contact EAS and/or the Consultant at least one week in advance.

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.

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.

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 [email protected]

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.

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.

PLEASE SELECT BELOW TO CONFIRM IF YOU HAVE READ EARLY AUTISM SERVICES, LLC’S INFORMED CONSENT AGREEMENT, AND CONFIRM THAT YOU ARE MAKING AN INFORMED CHOICE TO CONSENT YOUR CHILD TO EARLY AUTISM SERVICES, LLC’S SERVICES/ THERAPY, AND UNDERSTAND AND ACCEPT THE TERMS OF THIS AGREEMENT.

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.

Using Your Managed Health Care Benefits If you choose to utilize your Managed Health Care benefits you will have to sign a release of information form giving your consultant permission to release clinical information to your Managed Health Care Company. Early Autism Services, LLC will make every effort to release only the minimum information about your Child that is necessary for the purpose requested. This information will become part of the insurance company/managed mental health company files and will probably be stored in a computer. Though all insurance companies state that they keep such information confidential, we have no control over what they do with it once it is in their hands. Your consultant and/or therapist will provide you with a copy of any report submitted to your Managed Health Care plan, if you request it in writing. Managed Care Limits on Treatment Please keep in mind that insurance plans (particularly Managed Care plans) may limit your mental health coverage to time limited short-term treatment approaches designed to work out specific problems that interfere with a person's usual level of functioning. They may also limit coverage to a certain dollar amount or number of sessions per year. Regardless of what insurance you have you need to carefully check your benefits so you are clear on the number of sessions/coverage available and any procedures necessary for having this coverage authorized. Please keep in mind that certain services, such as educational testing, may not be covered by your insurance. You may feel that your Child may need more services than your insurance will cover (i.e., wish to continue therapy after insurance benefits end). If you are seeking more long- term services/therapy for your Child or have concerns that require more extensive therapy we will need to make arrangements for payment once your insurance benefits are no longer available, or if your managed care insurance declines to coverage such treatment. Remember, you always have the right to pay for my services yourself to avoid the problems described above [unless prohibited by contract]. Collection Procedures We may use legal means, including hiring a collection agency or going through small claims court to collect outstanding balances. These actions will require the disclosure of otherwise confidential information. In most collection situations the only information released regarding a patient's treatment is his/her name, the nature of services provided, and the amount due. [If such legal action is necessary, its costs will be included in the claim].

By selecting that you "Agree" to the Informed Consent Agreement, the Parent hereby gives Early Autism Services, LLC (“EAS”) Consent and permission to bill the Parent’s insurance plan as designated below directly for EAS’s Services it provides to Parent’s Child. Parent shall exchange the information necessary to secure payment for EAS’s Services (including, but not limited to, the Child’s diagnosis, service dates, types of services, and any and all information needed to process the claims). Parent understands that if an insurance payment is made directly to him/her for EAS’s Services, the Parent is responsible for immediately sending payment to EAS. Parent shall notify EAS immediately of any changes made to his/her Child’s health insurance, including denial information.

1. Sharing information with Early Autism Services, LLC Staff Early Autism Services, LLC or EAS is a group practice with multiple therapists and administrative staff. Protected information will be shared with these individuals for clinical and administrative purposes, such as scheduling, billing, consultation, vacation/illness coverage and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All administrative staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. EAS staff routinely consults with one another about our work in order to improve the quality of our clinical services. We also share clinical information for coverage during illnesses and vacations. The only times we will not share information with a specific EAS therapist is when you specifically request this and this request is granted. Requests will be granted when you know a EAS therapist outside of the work setting, a EAS therapist is treating a spouse or family member and clinical practice dictates that the sharing of information might be problematic, or other specific circumstances agreed to by you and your therapist. For any such agreement to be valid the agreement must be noted in your clinical record. 2. Legal Mandates for Breaking Confidentiality There are some situations in which therapists are legally obligated to take actions, which they believe are necessary to attempt to protect others from harm even though such actions may reveal some information about a patient's treatment. These situations include: If therapist has reasonable cause to believe that a child under 18 known to therapist’s professional capacity may be an abused child or a neglected child, the law requires that therapist file a report with the local office of the Department of Children and Family Services. Once such a report is filed, therapist may be required to provide additional information. If therapist has reason to believe that an adult over the age of 60 living in a domestic situation has been abused or neglected in the preceding 12 months, the law requires that therapist file a report with the agency designated to receive such reports by the Department of Aging. Once such a report is filed, therapist may be required to provide additional information. If your Child has made a specific threat or violence against another or if therapist believe that your Child presents a clear, imminent risk of serious physical harm to another, therapist may be required disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking your Child’s hospitalization. If therapist believes that your Child present a clear, imminent risk of serious physical or mental injury or death to himself/herself, therapist may be required to disclose information in order to take protective actions. These actions may include seeking your Child’s hospitalization or contacting family members or others who can assist in protecting your Child.

A. PURPOSE: The following outlines Early Autism Services’ agency-wide policy for the involvement of any individual therapist or consultant in the planning and implementation of an Individualized Education Program (IEP). As is outlined below, the primary role of Early Autism Services in the IEP process is to ensure school readiness through in-home programming and to assist each family in securing an appropriate placement for their child. B. PERSONNEL INVOLVEMENT: The following outlines the role that each level of staff may take in the IEP process. This includes: a) behavioral technicians b) lead therapists and c) consultants (BCBA). 1. Behavioral Technicians are prohibited from attending an IEP meeting. 2. Consultants (BCBAs) may attend IEP meetings in the event that: • Time has been expressly allotted during the IEP meeting for the consultant to provide insight. • The IEP meeting does not interfere with any regularly scheduled sessions or team meetings. This includes sessions or meetings with the child in question and sessions or meetings with other children on the consultant’s caseload. 3. The role of BCBAs in the IEP process is limited to: • Planning and outlining a child’s goals. • Reviewing the notes and goals that result from an IEP meeting.

This Parent Consent Agreement hereinafter referred to as “Agreement” is entered into between Early Autism Services, LLC (“EAS”) and Payor Full Name (“Parent”) [Parent Name Provided Below] dated the [Date Provided Below]. Client Full Name [Child Name Provided Below] (“Child”) has been authorized to receive intensive behavior modification services (“Services”) from EAS. In order to assure that your child and family receive prompt, professional and competent Services from EAS the following guidelines have been developed. 1. During the first week of providing Services, we request that you become available to “shadow” Consultant and/or Therapist until they become familiar with your child and his/her schedules as well as get an intimate knowledge on the nature of his/her behaviors. 2. Please monitor your Child’s Services for the first couple of weeks and inform EAS immediately should there be a mismatch between your child and the Consultant and/or Therapist assigned to work with him/her. 3. Data will be collected throughout the entirety of the session and the last 15 to 20 minutes of your Services will be dedicated to filling out the daily notes in the Program Book. The collection of data is mandatory for the provision of Services. The Program Book shall be provided by EAS. Additionally, the fit between a child’s therapeutic needs and the program’s services is determined on an individual case basis by both the parent/guardian and the consultant. EAS provides services exclusively to children and adolescents under the age of 18 and their families. 4. Please allow an area where we can keep the Program Book in your We require the Program Book for the collection of our data. Only the Consultant, Therapist, any other designated agent of EAS, and/or parent will have access to the Program Book. 5. The Parent has the responsibility to inform the Consultant and/or Therapist of his/ her child’s relevant medical conditions; infectious diseases; allergies to medications and other substances; and any other relevant information in order to assist in developing a treatment plan. 6. The Parent agrees to engage and participate in a family education program for the Child’s care, treatment, and needs. 7. The Consultant or Therapist shall only provide Services to the Child designated in this agreement. 8. The Child’s parent or an appointed guardian shall be present at all times Services are provided to the Child by EAS. 9. If the parent will be away for any reason for any length of time and the Parent has designated a guardian; another family member and/or authorized agent (“Responsible Party”) to be present during the time when the Child is receiving Services by EAS, EAS requests that you advise the Consultant or Therapist at least one week in advance, so the Consultant or Therapist can make the necessary arrangements. 10.Video or audio recording of therapy sessions, team meetings, or in any other instance that involves personnel associated with EAS without the written consent of EAS and the representative of EAS being recorded is prohibited. Any recording must be done with the written consent of the individual therapist being recorded. Additionally, an authorized representative of EAS must also give written consent of any recording that takes place. 11.Representatives of EAS are prohibited from taking pictures, video, or audio recordings of a child or any other family. Additionally, EAS representatives are prohibited from posting any information to the Internet that pertains to a child’s ABA program. If you have a concern about the actions of any individual affiliated with EAS that pertain to this policy, please contact EAS immediately. 12.The parties understand that the Child's treatment and Services may change due to the Child's development and response to EAS shall discuss any additional treatment requirements and/or next level of Services with Parent prior to transitioning such treatment and Services to the Child. 13.Community outings will be limited to settings that do not require money (i.e. park, shopping mall, library, bookstore). When EAS takes the Child on a community outing as defined herein, the Parent and/or Responsible Party (as defined in Paragraph 9) shall be present. During the community outings, the Parent and/or Responsible Party are in charge and responsible for the Child’s well-being, care and are and to monitor the Child accordingly. Parent and/or Responsible Party hereby waives, releases, and discharges EAS, its owners, employees, and/or authorized agents from any and all liability, loss, cost, claim, damage, injury and/or cause of action of any kind arising out of the Child’s participation in a community outing. In addition, Parent and/or Responsible Party shall indemnify and hold harmless EAS, its owners, employees, and/ or authorized agents from any and all such liabilities or claims made as a result of the Child’s participation in the community outings. 14.Physical intervention by a therapist in the presence of aggressive behavior may be necessary at some point during a child’s program. The use of physical intervention is only considered when all other strategies have been exhausted. Furthermore, physical intervention or restraint will only be used if there is concern for the immediate safety of the child or the therapist. Please call your consultant, Mareiko Au, or Vincent Scarlata with any questions or concerns about EAS’s policy on physical intervention. 15.The Services not included in this Agreement are as follows: • The Consultant and/or Therapist shall not, under any circumstances, drive the Child in his/her private vehicles; • The Consultant and/or Therapist shall not administer medications to the Child. • The Consultant and/or Therapist shall not, under any circumstances, accompany the family and the Child on vacations; • The Consultant and/or Therapist is only responsible for the Child assigned to him/ her and may not be given other siblings and /or family members to supervise; • No money shall exchange between the Consultant and/or Therapist and the Parent; and • The Consultant and/or Therapist shall not act as a babysitter for your Child. 16.Under no circumstances will EAS support parents or the Consultant and/ or Therapist engaging in dual relationships that compromise the guidelines and integrity of EAS (i.e. parents will not promote and/or engage the Consultant and/or Therapist in personal relationships and/or professional opportunities outside of EAS services). Furthermore, at all times the parent(s) must respect boundaries of the Consultant and/ or 17.The Consultant arranges all schedules in coordination with parental input. At the onset of services should you require changes in the schedule, please notify the Consultant. The Therapist is not authorized to make any schedule changes. 18. EAS's owner is Benjamin Wessels. 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 contact either Mareiko Au or Vincent Scarlata at [email protected]. 19.Upon termination of this Agreement, EAS shall advise Parent of the Child's prognosis and information concerning the Child's continuing care and EAS will make available all necessary documentation and treatment records for continuity and coordination of care with subsequent providers. At the request of a parent/ guardian, EAS will contact subsequent providers with relevant information to ensure continuity of care.

I/we agree not to solicit or employ any employee or independent contractor of EAS, including Consultants or Therapists, in any manner including, but not limited to: • as an employee, consultant, or through a third party, other than general advertisement, without prior written approval by EAS during the term of this agreement and for at least two (2) years after the expiration, termination or conclusion of this agreement. • Unless otherwise agreed to by the Parties, in the event that I/we violate this section, I/we agree to pay EAS a fee of fifty percent (50%) of the gross annual salary paid by EAS to such employee or individual contractor, including Consultants or Therapist. Such fee shall be paid by me/us upon hiring of such employee or independent contractor, including Consultants or Therapists

It is the policy of Early Autism Services to afford Equal Employment Opportunities regardless of race, color, national origin, gender, age, marital status, religion, disability, sexual orientation, pregnancy, genetic conditions or predispositions, or certain military and veteran status. Further, all applicable laws relating to disability discrimination will be strictly followed. This policy of Equal Employment applies to all aspects of the employment relationship. I/we have read ad understood the materials included in the Consent Agreement as it relates to the provision of EAS's Services as authorized for my child. I/we agree to maintain confidentiality for all business policies, procedures, techniques, trade secrets, other knowledge or processes developed by EAS. I/we understand that all program materials are prepared solely for my/our use and cannot be copied, disseminated, published or shared with a third party without the approval of EAS. I/we understand that all program materials must be returned to EAS upon termination of this agreement.

a. Billing Policy Early Autism Services will bill patient responsibility amounts on a monthly billing cycle. Deductible, and co-insurance or co-pays, will be invoiced for services rendered. Billing will commence the month after services start and will continue to be billed until your out of pocket maximum has been met and Insurance is paying at 100%. b. Invoicing Monthly invoices will be sent no later than the 10th business day each month and will be calculated on the insurance benefits that we have previously discussed with you. If for any reason claims are not paid according to that schedule, we will immediately make corrections and either issue a new invoice with corrected new amount due, apply any overage to a future invoice or issue a refund. c. Payment Payment for Services shall be paid 30 days after receipt of invoice. Please note that you are responsible for the charges you incur from our services per the discussion explaining your insurance benefits. CEAS charges a $75.00 fee for checks returned due to insufficient funds. Payment for “other services” as defined in Section 5 of the parent agreement, will be discussed at the time these services are requested. d. Secondary Policy Coverage It is the responsibility of you the client, to inform Early Autism Services of any secondary insurance coverage. This includes but is not limited to any Medicaid or state assistance. If we are not informed of this coverage prior to the start of services it is possible that we will not be able to get back coverage, and you would be liable for any out of pocket expenses incurred. e. Payment Plans A Payment plan may be available to families if required. A payment plan must be discussed prior to services beginning, or prior to a new year of services for existing clients. If a payment plan is needed, please immediately reach out to a billing team representative. f. Discounts Early Autism Services understands that paying for services requires a lot, and as such we are happy to offer a 10% discount for all clients who pay invoices in full and on time. On the last invoice of the year we will apply a 10% discount to the entire out of pocket maximum for the year. Further, if a client would like to pay their out of pocket up front, we will offer a 15% discount to the overall out of pocket maximum for the year (this must be discussed before services begin, or before the end of January for a new service year) g. Financial Assistance Early Autism Services does offer financial assistance to our families in need. Our financial assistance policy allows families to submit for a reduced rate and is assessed on a case by case basis. The policy is largely based on the Health and Human Services federal poverty guidelines, and although your family may make more than the guideline level, we do offer assistance to families that make above and beyond guideline levels as well. If you feel that the burden of your out of pocket may be too much for your family, please reach out to the billing team for the financial assistance form.

a. Late Fees i. The first occurrence of a late payment will be forgiven if it is resolved swiftly and discussed with a billing representative. ii. The second occurrence will result in a 5% late fee assessed on the overdue invoice. iii. The third occurrence will result in a 10% late fee assessed on any and all outstanding invoices. b. Balance Carryover Early Autism Services understands that the financial burden of services is high, and as such we can and will discuss a balance carryover into a new service year. A balance carryover cannot exceed more than half of the annual out of pocket maximum, and there must be an agreed upon payment plan in place to catch up payments in the new calendar year. If these things are not in place and we are unable to reach you to discuss the payment plan, we will work on a transition out plan prior to the new year beginning. c. Non-Payment If a family has not made a payment and has not spoken with a billing representative, we will exercise every avenue we have to try and discuss the Parent Contract Agreement invoice with you. This includes but is not limited to calling and emailing with the information provided at intake and having your clinician request that you get in contact with the billing team. If no contact is made and no payment is received 90 days after an invoice has been sent, we will begin to work on a transition of services plan. If no payment is made at that time, we will continue to work with you to collect owed amounts for 100 days, at which time we will send your invoices to collections.