New Client Forms
Dear Family,


Starting therapy for your child can be exciting as well as overwhelming. We will work together to achieve the goals you set for your child. Included in this packet are a significant number of forms. Please feel free to ask me any question you have via email or phone.


I am excited to embark on this journey with your family.

Sincerely,
Rosalie

An Overview of Eclipse Therapy LLC’s Approach

Mission:

To ensure that every family has the opportunity to enjoy the simple pleasures of life: a peaceful family dinner, a quiet game of cards, a movie night out, or an event-free trip to the grocery store. Eclipse will provide consistent and exceptional behavior analytic services to children with disabilities. Services are provided to optimize the child's progress towards their individualized goal. 


Purpose:

The cornerstone of Eclipse Therapy is the understanding that any impairment or disability can have a debilitating effect on an individual and the family. With steadfast loyalty, Eclipse will strive tenaciously to increase the child’s abilities in an effort to improve the functioning of the child and furthermore increase harmony within the family.

Our approach to working with each child:
• Is individually tailored to meet each child's unique needs
• Is optimized to ensure your child is gaining skills as quickly as possible
• Is based on the most current research
Our programing for autism addresses the major issues common in autism:
• Understanding and using language
• Building broader social skills
• Communicating with and relating to peers
• Building age appropriate and symbolic and play skills
• Building emotional regulation skills
• Increasing flexibility and reducing rigidity
• Increasing conceptual thinking and cognitive skills

Our programing for children with other disorders is individual tailored but will include these essential skills:
• Building emotional regulation skills
• Increasing distress tolerance
• Increasing communicative abilities
• Increasing conceptual thinking and cognitive skills

Eclipse Therapy’s trained therapists work one-on-one with each child closely monitoring responses in order to match the difficulty of the material and method of instruction to the child's ability level and rate of learning. All our therapists hold at least a bachelors degree, have extensive training specifically in research supported treatments for autism spectrum disorders, behavior disorders, and the principals of Applied Behavior Analysis. Supervision of each child's program is provided by one of our BCBA with regular progress reviews monthly during a team meeting at your home.
In addition to the individual ABA program, parent training, programs to address problem behaviors, and a range of behavior analytic services are offered through out our sessions. Our focus is on helping your child gain skills that are critical to your family and their functioning.

We provide behavioral assessments, parent & staff training, program supervision, and quality in home/school ABA programing. Each of our program supervisors is board certified by the Behavior Analysis Certification Board.
Please call 720-339-1309 for further information or clarification.
Instructions for this packet of information

This packet is rather lengthy, but it will help the Eclipse team better understand your child and the skills they need to acquire or maladaptive behaviors we need to help reduce. Please be as detailed as you can. If something does not apply to your child please write NA.

This is an electronic version of our PDF printable form. By checking the boxes and typing your name you are electronically signing these documents. If you prefer a PDF version is available by request.

Please complete all of the required fields. After you have completed them please click submit and an Eclipse clinician will be with you as soon as possible.

We look forward to working with your family! Please do not hesitate to call or email with any questions or concerns.


Email address *
Consent to Treat
I, the undersigned parent, person having legal custody or guardianship/authorized care provider of the below minor, do hereby authorize Rosalie Byrd Prendergast, MS BCBA and any of the other Eclipse Therapy, LLC clinicians to provide and/or supervise behavioral health services. Such services may include, but are not limited to Behavioral Assessment, Behavioral Treatment, and Counseling Services. I understand this authorization may be revoked in writing at any time.

Additional Clinicians:
Rosalie Byrd Prendergast, MS BCBA
Eugenia Logvinova, Med BCBA
Katherine Thomas, MS BCBA
Amanda Montoya, MS BCBA
Timothy Mullins, MFTC
Britney Bonner, MFTC
Damian Young, LMFT
Kristy O’Brien, BCABA

Type the Name and Date of Birth for the Minor you are providing consent to treat. *
Your answer
By typing your name and date below your are agreeing to electronically signing the above consent to treat. *
Your answer
Mandatory Disclosure
Mandatory Disclosure Statement
1. Name of Therapist: Rosalie Byrd Prendergast, MS BCBA

2. Degrees: BA, University of Northern Colorado, 2004
MS, Nova Southeastern University, 2009
Board Certified Behavior Analyst, 2009
Unlicensed Psychotherapist #12185, 2010

3. Agencies I report to:
a. The Colorado Department of Regularly Agencies has the general responsibility of regulating the practice of licensed psychologists, licensed clinical social workers, licensed professional counselors, licensed marriage and family therapists, certified school psychologist, and unlicensed individuals who practice psychotherapy. The agency within Office of Licensing Unlicensed Psychotherapist 1560 Broadway, Suite 1350 Denver, CO 80202, (800) 811-7648.
b. I am also regulated by the Behavior Analyst Certification Board. They can be reached at Behavior Analyst Certification Board 2888 Remington Green Lane, Suite C Tallahassee, FL 32308 850-765-0905

4. Client Rights and Important Information:

a. You are entitled to receive information from me about my methods of therapy, the techniques I use, the duration of your therapy (if I can determine it), and my fee structure. Please ask if you would like to receive this information.

b. You can seek a second opinion from another therapist or terminate therapy at any time.

c. In a professional relationship (such as ours), sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs, it should be reported to the State Board of Psychologist Examiners.

d. Generally speaking, the information provided by and to a client during therapy sessions is legally confidential if the therapist is a certified school psychologist, a licensed clinical social worker, a licensed marriage and family therapist, a licensed professional counselor, a licensed psychologist, or an unlicensed psychotherapist. If the information is legally confidential, the therapist cannot be forced to disclose the information without the client’s consent.

e. There are exceptions to the general rule of legal confidentiality. Some of these exceptions are listed in the Colorado statutes (see section 12-43-218, C.R.S, in particular). For example, I am required by law to report child abuse. There are other exceptions that I will attempt to identify to you, if feasible at the time, as situations arise during therapy.

Request additional disclosures:

Rosalie Byrd Prendergast, MS BCBA
Eugenia Logvinova, Med BCBA
Katherine Thomas, MS BCBA
Amanda Montoya, MS BCBA
Timothy Mullins, MFTC
Britney Bonner, MFTC
Damian Young, LMFT
Kristy O’Brien, BCABA

By typing your name and date below your are agreeing to electronically signing the above consent to treat. *
Your answer
Non-Discrimination Policy Statement

It is the policy of Eclipse Therapy to provide services to all persons without regard to race, color, national origin, religion, sex, age, or disability. No person shall be excluded from participation in, or be denied benefits of, and service; or be subjected to discrimination because of race, color, national origin, religion, sex, age, or disability.

Complaint of discrimination policy and procedure: this policy statement complies with Civil Rights Act, Title VI (45CFR part 80.7 B) and section 504 of the Rehabilitation Act of 1973 (45 CFR part 84.7 b. If you feel that you have been denied a benefit or service because of your race, color, national origin, age, sex, disability, or religion you may file a Complaint of Discrimination with the facility administrator of Eclipse Therapy, either verbally or in writing. A written response will be issued to you within 21 days of the complaint notice.

You may also file a complaint with an external agency. If you choose to file your complaint in writing, you must include your name, address, telephone number, and a brief description of what occurred which led you to believe you were discriminated against. If you need assistance, the facility administrator of Eclipse therapy will be able to assist you

You may also file a complaint of discrimination by calling or writing the Department of Regulatory Agencies (DORA) Division of Civil Rights at (303) 894-2997 or 1560 Broadway #1050, Denver, CO 80202

By typing your name and date below your are accepting receipt of the above non-discrimination policy. *
Your answer
Fee Schedule
Behavioral Consultation with Rosalie Byrd Prendergast, MS BCBA, Eugenia Logvinova, Med BCBA, Katherine Thomas, MS BCBA, Amanda Montoya, Med BCBA,:
$140 per hour plus $40 per hour traveled according to Google Maps.

In Home/School Behavior Therapy Masters level clinician:
$120 per hour plus $0.555 per mile traveled round trip according to Google Maps.

In Home/School Behavior Therapy with RBT Level Clinician Pursuing Certification:
$85 per hour plus $0.555 per mile traveled round trip according to Google Maps.

In Home/School Behavior Therapy with RBT Level Clinician:
$50 per hour plus $0.555 per mile traveled round trip according to Google Maps.


Additional Charges applying to all services:
These services maybe necessary for your program and are billed at your clinicians rate hourly rate.
o Phone consultation lasting more than 15 minutes.
o Written documentation (including progress reports and other forms of written communication) requiring more than 15 minutes
o Email messages requiring more than 15 minutes.
o Written or verbal communication with 3rd party payers (including insurance carriers, Community Centered Boards, etc.) requiring more than 15 minutes.
o Creation of individualized therapy materials such as, but not limited to books or stories requiring more than 15 minutes.
o Record review requiring more than 15 minutes.
o Other services a client may request requiring more than 15 minutes.

By typing your name and date below your are accepting receipt of the above fee schedule. *
Your answer
PAYMENT POLICY

Eclipse Therapy LLC strives to offer the highest quality of care. Never will your care be contingent on your insurance or waiver coverage. Considerable care has been taken to determine our rates. We want to assure you that our charges accurately reflect the complexity of care rendered and the skill and expertise required for optimal treatment. Our fees are comparable to those of other highly qualified specialists. Whether you have purchased insurance on your own, your employer has provided it to you, or you have qualified for a medicaid waiver, you are fortunate to have it and we will go the extra mile to help you maximize your benefits provided by your specific plan or waiver. As a courtesy to you, we will file with those plans to which we have been admitted as a provider (In Network) and when requested and we have not been admitted as a provider will complete the standard CMS1500 claim form for you to seek reimbursement through your insurer. When a service is covered, your insurance company usually only pays a percentage of the fee, and this varies from carrier to carrier and plan to plan. Your insurance is not designed to pay the entire cost of treatment, but it is intended to help cover a certain portion of the cost.

Please remember, however, the financial obligation for our services is between you and this office, and is NOT between this office and the insurance company.

For clients choosing to private pay for services, you will be billed monthly via our QuickBooks online accounting system. You will receive a bill between the 1st and 4th of the month following services. Payment for these services is due back 30 days from receipt of the invoice from Eclipse Therapy LLC.

Payment to our office is not contingent, nor dependent upon your insurance company. All account balances must be satisfied within 60 days of the date services were billed, after that time a rebilling fee of $10.00 may be charged to your account. If you have any questions regarding our financial policy, please do not hesitate to discuss them
with us.

We accept cash, check, and bank transfers via QuickBooks online.

I understand and agree that I am responsible for the payment of all charges incurred regardless of any insurance coverage or other plans available to me. Additionally, I understand and agree to pay any and all collections costs and/or attorney’s fees if any delinquent balance is placed with an agency or attorney for collection, suit, or legal action. I also acknowledge that confidentiality is waived in matters involving collections and the sharing of information sufficient to pursue recovery of debts owed.

By typing your name and date below your are accepting receipt of the above payment policy. *
Your answer
Using Waiver Services
You will need to fill out the section below. If you are not using waiver services please skip to your designated funding source.
Who is your Community Center Board?
Who is your Case Manager and their email?
Your answer
Please note that we cannot begin services until we have Authorization in writing from your Case Manager.
If you would like to begin services on a private pay basis prior to approval please type your name and date below as your electronic signature recognizing that you will be billed at private pay rates until your waiver services have been approved.
Your answer
Please type your name and date below in understanding that if you schedule more hours than are approved through your waiver, you will be billed at private pay rates.
Your answer
Assignment of Benefits
I authorize payment of behavior health benefits to Eclipse Therapy LLC and/or clinicians at Eclipse Therapy LLC for these services and all future claims. You should also understand you will be responsible for all non-covered services because of lack of authorization or for any other reason for denial.
By typing your name and date below your are accepting receipt of the above assignment of benefits. *
Your answer
Using Insurance
If you plan to use Private Insurance or Medicaid please fill out the following questions . Please not private insurance does not typically cover services for diagnosis other than Autism.
Insurance Company
Your answer
Policy Number
Your answer
Group Number
Your answer
Policy Holder Name and Date of Birth
Your answer
Date of diagnosis
MM
/
DD
/
YYYY
Please provide a copy of your card via email, photo, or paper.
HIPAA Email Consent
VERY IMPORTANT! PLEASE READ!
• HIPAA stands for the Health Insurance Portability and Accountability Act HIPAA was passed by the U.S. government in 1996 in order to establish privacy and security protections for 
health information
• Information stored on our computers is encrypted. Most popular email services (ex. Hotmail®, Gmail®, Yahoo®) do not utilize encrypted email
• When we send you an email, or you send us an email, the information that is sent is not encrypted. This 
means a third party may be able to access the information and read it since it is transmitted over the Internet. 
In addition, once the email is received by you, someone may be able to access your email account and read it.
• Email is a very popular and convenient way to communicate for a lot of people, so in their latest modification to the HIPAA act, the federal government provided guidance on email and HIPAA The information is available in a pdf (page 5634) on the U.S. Department of Health and Human Services website ‐ http://www.gpo.gov/fdsys/pkg/FR‐2013‐01‐25/pdf/2013‐01073.pdf
• The guidelines state that if a patient has been made aware of the risks of unencrypted email, and that same patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email 


OPTION 1 – ALLOW UNENCRYPTED EMAIL
I understand the risks of unencrypted email and do hereby give permission to the Austin Med Clinic to send me personal health information via unencrypted email

OPTION 2 – DO NOT ALLOW UNENCRYPTED EMAIL
I do not wish to receive personal health information via email

Please type your selection below. *
Your answer
If you have chosen to allow UNENCRYPTED EMAIL please type your email below. If you have decided not to allow please type "do not allow".
Your answer
Permission to Photograph
I give permission and consent for Eclipse Therapy, LLC to take photos of my child and/or myself during the time my child is enrolled in services. I understand these photographs may be used in educational training presentations.
By typing your name and date below you are giving Eclipse Therapy LLC permission to photograph my child.
Your answer
Permission to Videotape or Audiotape
I give permission and consent for Eclipse Therapy, LLC to videotape and/or audio tape my child and/or myself during the time my child is enrolled in services. I understand these tapes will not be used outside the company and will be kept confidential. I understand that the tapes will be used for the purposes of developing more effective educational and therapeutic plans for my child and also for the purpose of education and training for Eclipse Therapy, LLC and the family.
By typing your name and date below you are giving Eclipse Therapy LLC permission to Videotape or Audiotape my child.
Your answer
In addition to the above, I also give permission for Eclipse Therapy, LLC to use recorded video segments to present to parents and professionals for conferences and/or other training purposes.
Your answer
CHILD & ADDOLESCENT INTAKE QUESTIONNAIRE
Confidential

The following questionnaire is to be completed by the child's parent or legal guardian. This form has been designed to provide essential information before your initial appointment in order to make the most productive and efficient use of our time. Please feel free to add any additional information, which you think, may be helpful in understanding your child. Eclipse Therapy, LLC will hold information provided by you is strictly confidential and will only be released in accordance with HIPPA guidelines and as mandated by law. Please use the backs of the pages for additional information.

Name of Person Completing this form *
Your answer
Legal Name of Child *
Your answer
Nickname or name child routinely goes by *
Your answer
Child's Date of Birth *
MM
/
DD
/
YYYY
Current Age
Your answer
Age of Diagnosis
Your answer
Home Address (Primary Residence): *
Your answer
Home Address (Secondary)
Your answer
Home Telephone Number (primary) *
Your answer
Home Telephone Number (Secondary):
Your answer
Mother Cell *
Your answer
Father Cell *
Your answer
School Name *
Your answer
Grade *
Your answer
School Telephone Number *
Your answer
Current Teacher *
Your answer
Who referred you to our practice? *
Your answer
Please describe the problems your child is now having, and what type of services you are seeking from us for these problems. *
Your answer
INDICATE PARRENT/GUARDIANS LIVING IN THE HOME
Marital Status *
If divorced, who has physical custody?
Your answer
Is it full or joint?
Your answer
Mothers Information
Mother's Name *
Your answer
Date of birth *
MM
/
DD
/
YYYY
Age *
Your answer
Occupation *
Your answer
SSN
Your answer
Employer *
Your answer
Email *
Your answer
Education Completed *
Health *
Father's Information
Father's Name *
Your answer
Date of birth *
MM
/
DD
/
YYYY
Age *
Your answer
Occupation *
Your answer
SSN
Your answer
Employer *
Your answer
Email *
Your answer
Education Completed *
Health *
Does either parent's job require him/her to be away from home long hours or extended periods? *
Religious/Spiritual Affiliation
Your answer
Does any one in the home have a current or past substance abuse? If yes please explain.
Your answer
Siblings, please list each sibling, their age, current school and grade. *
Your answer
Is there a history of:
Yes
No
Sibling
Paternal Aunt or Uncle
Maternal Aunt or Uncle
Paternal Grandmother or Grandfather
Maternal Grandmother or Grandfather
Other relative
Autism Spectrum Disorders
Learning Problems/Disabilities
ADHD/Attention Problems
Depression
Depression and Mania
Behavior Problems in School
Anxiety
Mental Retardation
Psychosis
Substance Abuse/Dependence
Other Mental Health Concern
Has the child you are seeking services for been evaluated in the past? *
If they have been evaluated please provide the type of evaluation, when it occurred, and who completed the evaluation. If possible provide a copy.
Your answer
If yes, what were the findings of the evaluation?
Your answer
Please provide us with any other information on the psychological history that you feel would be helpful to us in understanding your child.
Your answer
PRE-NATAL AND DELIVERY HISTORY
Were there any complications with the Pregnancy? *
Required
If Yes, please provide treatment details
Your answer
Was birth at Full Term? *
If No, please provide detail
Your answer
Type of delivery *
Birth Weight *
Your answer
Apgar Scores *
Your answer
Concerns at birth? *
If Yes, please provide detail - including any treatments given
Your answer
Is there any additional pre-natal or birth information that might be of assistance to us?
Your answer
DEVELOPMENTAL HISTORY
Please indicate the age that your child consistently did the following:
Rolled over *
Your answer
Sat up unsupported *
Your answer
Stood *
Your answer
Crawled *
Your answer
Walked *
Your answer
Dressed Self *
Your answer
1 st words *
Your answer
Said Intelligible work to stranger
Your answer
Used phrases *
Your answer
Talked in sentences *
Your answer
Potty trained during the day *
Your answer
Dry through the night (6+ months) *
Your answer
Areas of Challenge
Please indicate if you child is experiencing any of the following
Problems with eating *
Isolated socially from peers *
Problems making friends *
Problems getting to sleep *
Problems controlling temper *
Nightmares
Bed Wetting / Soiling *
Problems with authority *
Anxiety *
Unmotivated *
School concentration difficulties *
Grades dropping or consistently low *
Sadness or Depression *
Substance Abuse *
List any operation, serious illnesses, injuries (especially head), hospitalizations, allergies, ear infections, or other special conditions your child has had.
Your answer
List any medications your child is currently taking or has taken for extended periods (give dosage level if possible) *
Your answer
Child's current height *
Your answer
Child's current weight *
Your answer
With which hand does the child write?
Does the child have any vision problems?
Please list date of last vision test and who performed (pediatrician, optometrist, School)
Your answer
Does the child have any hearing problems?
Please list date of last hearing test and who performed (pediatrician, optometrist, School)
Your answer
Name of child's physician(s) *
Your answer
Practice Name *
Your answer
Address *
Your answer
Phone Number *
Your answer
Fax Number *
Your answer
Educational History
List in chronological order all schools you child has attended (school, district, years) *
Your answer
Is your child receiving special education services *
Names of current teachers *
Your answer
Does your child's teacher have concerns about him or her? *
Your answer
What is your child's favorite subject or class? *
Your answer
What is your child's least preferred subject or class? *
Your answer
Has your child ever repeated a grade? *
If your child s been in special education, did they have a *
Required
If your child has been in Special Education, how were they served *
Required
Child's extracurricular activities (please list) *
Your answer
List any special abilities, skills, strengths your child has *
Your answer
Do you feel your child's academic skill level is appropriate? *
Would you like us to address academic skills development? *
Counting
Can your child identify numbers *
Required
Can your child count out a number of objects? *
Required
Can your child identity double digit numbers? 10-99
Can he/she complete simple addition math problems? (Single digit) *
Required
Can he/she complete simple subtraction math problems *
Required
Any other number skills you would like us to know?
Your answer
Reading
Can your child identify lowercase letters? *
Required
Can your child identify uppercase letters? *
Required
Can your child identify letter sounds? *
Required
Can your child identify letter blends (sh, st, cr)? *
Required
Can your child sound out words with blends? *
Required
Can read simple words (2-4 letters) *
Required
Can read longer words and site words *
Required
Can sound out unknown words *
Required
Can read complete sentences *
Required
Can comprehend what he/she is reading *
Required
Reading Comments
Your answer
Self Care and Adaptive Behaviors
Does your child dress him/herself? *
Required
Does your child bathe him/herself? *
Required
Does your child Grooming (brushing teeth, combing hair) him/herself? *
Required
Does your child clean up after him/herself? *
Required
Do you have safety concerns? *
Required
Please explain your safety concerns *
Your answer
Self Care Comments
Your answer
Engagement and Attending
Does your child make eye contact with others? *
Required
Answer or look when name is called? *
Required
Does your child engage in activities or games that are not their idea? *
Required
Can your child appropriately play by him/herself? *
Required
Can your child answer questions when there is background noise, other people, or distractions? *
Required
Does your child appear to understand directions and questions?
Does your child appear to have a good memory *
Required
Attending Comments
Your answer
Behavior
Tantrums, Aggression, Self-Injury: Does your child have tantrums that we need to address? *
Required
Describe the behavior *
Your answer
What triggers a tantrum? *
Your answer
When told "no" *
Required
When he/she is not getting attention or wants attention *