Informed Consent Agreement
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: www.earlyautismservices.com
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
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. FEES FOR SERVICES; COURT RELATED SERVICES AND INSURANCE
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. Court related services include talking with attorneys, preparing
documents, depositions, travel time, preparation for testimony and court
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
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
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.
5. 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
6. 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.
7. 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.
PLEASE MAKE YOUR SELECTION BELOW TO CONFIRM THAT YOU HAVE READ EARLY AUTISM SERVICES, LLC’S INFORMED CONSENT AGREEMENT, AND 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.