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.
An Overview of Eclipse Therapy LLC’s Approach
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 researchOur 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.
Additional Clinicians:Rosalie Byrd Prendergast, MS BCBA Eugenia Logvinova, Med BCBAKatherine Thomas, MS BCBAAmanda Montoya, MS BCBATimothy Mullins, MFTCBritney Bonner, MFTCDamian Young, LMFTKristy O’Brien, BCABA
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 BCBAKatherine Thomas, MS BCBAAmanda Montoya, MS BCBATimothy Mullins, MFTCBritney Bonner, MFTCDamian Young, LMFTKristy O’Brien, BCABA
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
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 minuteso 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.
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 themwith 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.
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
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.