POTTERHOUSE

tERMS & cONDITIONS

This document encompasses important information regarding Potterhouse Behavioral Health Services’ Applied Behavior Analysis (ABA) practice policies and professional services. It is necessary to thoroughly read through the following information (as well as information from the treatment plan) and ask for clarification at any time. Upon signing this agreement, you, the consumer, will adhere to an agreement between you and Potterhouse Behavioral Health Services to provide ABA services.

sERVICEs

Potterhouse Behavioral Health Services abides by the Behavior Analyst Certification Board (BACB) Guidelines for Responsible Conduct

● Services will be based on the development and implementation of a functional behavioral assessment and an ABA treatment plan. ABA services will be provided by a Board-Certified Behavior Analyst (BCBA).

● Potterhouse Behavioral Health Services provides ABA services based upon the client’s current level of individualized needs. The treatment plan will contain antecedent and consequence-based strategies that are skill-based, functionally equivalent, and non-aversive.

● Potterhouse Behavioral Health Services abides by HIPPA and BACB Ethical Standards regarding confidentiality. The client’s information will never be shared with others aside from authorized personnel. This includes household parents/caregivers.

● Sessions include training and ongoing consultation following the research-based principles of ABA.

● While you have the right to enroll your child in any program you deem appropriate, due our ethical guidelines, we cannot advise services that do not have research and scientifically established methods supporting them. Suggestions of other providers for techniques or goals to be incorporated in ABA therapy will be taken into account by the BCBA but they reserve the right to refuse implementation if it is outside our scope of practice or is in opposition to the researched, scientifically based practices that we adhere to. Potterhouse does not provide in-person ABA intervention therapy for parents and caregivers. If more frequent and intensive intervention is desired, the parent or caregiver should seek in-home, in-school, or clinic-based services from another provider.

Assessment, Participation, and Standard Treatment Procedures

Caregiver participation is a mandatory expectation of the delivery of services. Participation may involve team meetings, data collection, and more importantly, implementation and involvement in the implementation of recommended strategies. Specific levels of involvement will be discussed/ agreed to at the outset of service implementation. If there is a lack of involvement, Potterhouse Behavioral Health Services reserves the right to reconsider the appropriateness of services. Sessions will involve progress monitoring, abrupt changes in behavior, major transitions, the current level of service needed, and potential barriers in treatment to strive toward positive results. To achieve consistency across settings, generalization of skills, and increased likelihood of success, caregiver training will be a necessary component for your child’s progress and implementation of services. Caregiver meetings are scheduled by the caregiver through Potterhouse Behavioral Health Services.

Upon written agreement, an initial assessment will be scheduled. Potterhouse Behavioral Health Services strives to provide non-aversive care using an integrated treatment approach to create a positive learning experience for any individual. An initial assessment may include observations of clients in the potential treatment setting and interviews with family members. During an assessment interview, Potterhouse Behavioral Health Services also asks that our clients and/or families share information about an individual’s preferences, dislikes, and needs that may arise during a clinical assessment as well as to provide input into the treatment plan. Initial interviews may be conducted determine appropriate and effective recommendations. If at any time you have questions about the content/schedule of therapy, contact your behavior analyst.

Services are implemented by a Board-Certified Behavior Analyst. Supervision may occur in person or via HIPAA-compliant telehealth platforms.

Evaluations

Potterhouse Behavioral Health Services employees endure consistent evaluations via caregiver interviews and data. It is vital to receive caaregiver input in relation to these evaluations so we can ensure to provide consistent, productive, and effective ABA services for you and your child(ren). We will be requesting caregivers to fill out a satisfaction survey in order to gauge your perception of quality of care. We know your time is valuable and we greatly appreciate your time and consideration helping us improve and maintain our quality of services Potterhouse Behavioral Health Services staff provides.

If at any time you feel as though staff members are not providing high quality services, please contact Petra Allen, Owner of Potterhouse Behavioral Health Services, for any concerns. Your concerns will be held confidential, however, will be addressed in a timely and efficient manner. Contact information can be found in the Communication Section of this Contract.

Appointments & Cancellation Policy

Potterhouse Behavioral Health Services is committed to providing consistent and reliable services as scheduled and agreed upon by the client/family. Upon initial treatment, a preliminary set of hours/days for ABA services are discussed. Changes to this schedule will require notice. Regular attendance is key to seeing progress in your child’s therapy session. Please refer to our cancellation policy below:

Sessions cancelled with at least 24 hours prior notice will not be charged.
Sessions cancelled with less than 24 hours will be charged the session fee.

Communication

Potterhouse Behavioral Health Services is committed to responding to any questions, comments, or concerns regarding ABA services in a timely manner. We strive to provide the best quality services to clients, which includes timely and professional communication. The clients will be provided with telephone numbers and email addresses of those individuals involved in direct treatment services and planning. However, basic information regarding Potterhouse Behavioral Health Services’ services can be easily viewed at potterhousebhs.com.

Potterhouse Behavioral Health Services does not offer on-call coverage for ABA services and programs on a 24-hour basis. Clients may contact the provider via email. In case of emergencies, please dial 911.

Potterhouse Behavioral Health Services Directory Contacts:

Petra Allen, Owner – potterhousebhs@gmail.com

Potterhouse Behavioral Health Services strives to provide the best services to our clients. We uphold our staff to the highest professional standards. Employees are expected to communicate with clients and caregivers with utmost respect. We also expect caregivers to interact with our staff respectfully and appropriately. This includes inappropriate conversations with staff, abusive language, physical altercations, etc. Any concerns of treatment should be addressed with Petra Allen directly, by phone or email.

Potterhouse Behavioral Health Services employees are required to maintain professional boundaries with clients and their families. We will never solicit or accept testimonials regarding our services, allow personal or charitable fundraising, accept gifts, or post client information on websites, social media, or other photo sharing sites.

Methods of Communication

Potterhouse Behavioral Health Services uses email, text messages, and phone calls as diverse platforms of communication. Documents may be delivered electronically and requested for signature via DocuSign. If you would prefer paper copies, please notify the Owner your preference of document delivery and processing. In the event paper copies are preferred, there may be delays in document delivery, insurance processing, and or scheduling for the learner.

Your consent for document delivery and methods of communication can be found on the Consent for Electronic Delivery and Communication form. If at any time your preferred method of communication changes, please allow up to 10 business days for processing and paper delivery to reflect preferred modifications. ADD HIPAA

Client Rights

Clients/Guardians have the right:

to be informed of all treatment procedures including risks and benefits
to have input on treatment plans including goals, reinforcement, potential aversive protocols, etc.
to request copies of medical files including treatment plans, progress charts, etc.
to ask for staff changes
to refuse treatment suggestions

Informed consent

Agreeing to these terms and conditions indicates you have received and read the information in this document. Consent by all caregivers is required for implementation of ABA services. By signing this agreement, you consent to receiving ABA treatment in the manner in which it’s described above. These policies have been fully explained to me and I have had all questions answered in relation to the information provided in this document. I also understand I have the right to withdraw my consent at any time. I fully and freely give my consent for services to be implemented as proposed.