ABA Intake Packet

We would like to extend a warm welcome to you on behalf of the staff at MCS! MCS is committed to providing supports that enhance the capacities of individuals with autism and their families, to maximize their quality of life as individuals and as members of the larger community.

Applied Behavior Analysis (ABA) is an inclusive term that covers a wide range of therapeutic approaches. “ABA is the science in which tactics derived from the principles of behavior are applied systematically to improve socially significant behavior and experimentation is used to identify the variables responsible for behavior change”. The behaviors we target for change are behaviors that can have real-life applications for the person receiving services. ABA is a lifestyle change and may not be as successful if done occasionally or part-time. It requires intensive commitment from the entire family. Services are provided in-home or out in the community with the caregivers present. The individual’s team may consist of 2-3 therapists who include a BCBA and 1-2 ABA therapists. The amount of hours allotted per week to the individual will vary depending on their level of need and approval through his/her insurance company. The BCBA from MCS will meet with you, identify your needs and concerns and develop a treatment plan with measurable goals and objectives.

Applied Behavior Analysis (ABA) is a therapeutic approach primarily used for individuals with autism and other developmental disorders. Here are some of the key risks and benefits associated with ABA.

Benefits

Skill Development: ABA can help individuals learn important life skills, including communication, social interactions, and daily living skills.
Behavior Modification: It effectively reduces challenging behaviors by using reinforcement strategies, helping individuals behave more appropriately in various settings.
Individualized Programs: ABA is tailored to meet the specific needs of each individual, allowing for personalized interventions that target unique challenges and strengths.
Evidence-Based: ABA is supported by extensive research and has been shown to produce positive outcomes for many individuals with autism and related conditions.
Parental Involvement: ABA programs often involve training for parents and caregivers, enabling them to support skill development and behavior management at home.

Risks

Over-Reliance on Rewards: Some critics argue that excessive use of reinforcement can lead to dependence on rewards rather than fostering intrinsic motivation.
Lack of Generalization: Skills learned in a therapeutic setting may not always transfer to real-world situations, limiting their effectiveness.
Potential for Misuse: If not implemented correctly, ABA techniques can lead to frustration or stress for the individual, especially if methods are too rigid or punitive.
Variability in Quality: The effectiveness of ABA can vary significantly depending on the practitioner’s training and approach, which can lead to inconsistent outcomes.
Controversial Practices: Some traditional ABA methods have been criticized for being overly focused on compliance and may not respect the individual’s autonomy and preferences.

Conclusion

While ABA can provide significant benefits for individuals with autism, it’s essential for practitioners to be mindful of the potential risks and to implement strategies that promote the individual’s well-being and autonomy. Engaging with families and adapting approaches based on individual needs is crucial for positive outcomes.

While services are individualized and designed to support the client’s unique goals and needs, it is important to maintain realistic expectations about the outcomes of treatment. Progress may vary depending on a range of factors including, but not limited to, the client’s participation, consistency of attendance, environmental influences, family or caregiver involvement, and the complexity of presenting concerns.

Treatment is not a guarantee of specific results or timelines. Although many clients experience meaningful improvements, gains may occur gradually, and some goals may require ongoing support. Regular reviews and data-driven assessments will guide adjustments to the treatment plan to best support progress.

Clear communication, active participation, and a collaborative approach between clients, caregivers, and the treatment team are essential for maximizing the effectiveness of services.

Today's Date(Required)

Parent/Guardian Name(Required)

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Parent/Guardian Signature(Required)

Client Rights

To ensure that all clients receiving services are treated with dignity and respect, and that their rights are protected in accordance with ethical, legal, and professional standards, clients have the right to:

Respect and Dignity: Be treated with respect, compassion, and courtesy by all staff, regardless of age, race, ethnicity, gender, religion, sexual orientation, disability, language, or socioeconomic status.
Confidentiality: Have their personal health and service information kept confidential, in compliance with HIPAA and relevant state laws, unless disclosure is authorized or legally required.
Informed Consent: Be fully informed about the services being provided, including the nature, purpose, risks, and benefits, and to provide informed consent before beginning services.
Participation in Services: Actively participate in the planning and decision-making process of their treatment or service plan and to refuse or request changes in services.
Access to Records: Review their own service records and receive a copy upon request, subject to legal and clinical considerations.
Grievance Process: File complaints or grievances without fear of retaliation and receive a timely and appropriate response.
Cultural Competence: Receive services in a manner that is culturally and linguistically appropriate to their needs.
Least Restrictive Environment: Receive services in the least restrictive, most integrated setting appropriate to their needs.
Freedom from Abuse and Exploitation: Be protected from physical, emotional, sexual, or financial abuse or exploitation by staff or others.
Continuity of Care: Receive continuous and coordinated services, including appropriate referrals and transitions when necessary.

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Parent/Guardian Name(Required)

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Requesting ADA Accommodations

Multicultural Community Services of the Pioneer Valley, Inc. (MCS) is committed to providing equal access and opportunity to individuals with disabilities in compliance with the Americans with Disabilities Act (ADA) and applicable state laws.

Individuals who require a reasonable accommodation to participate in any aspect of services, employment, or the application process may submit a request for accommodation. Requests should include a description of the accommodation being sought and, if applicable, documentation supporting the need for accommodation.

Requests for ADA accommodations can be made verbally or in writing to:

ABA Program Director
Multicultural Community Services of the Pioneer Valley, Inc.
Email: laurenjackson@mcsnet.org
Phone: 413-200-7407

All requests will be reviewed promptly, and MCS will engage in an interactive process to identify reasonable accommodations. Confidentiality will be maintained throughout the process, and no individual will be retaliated against for requesting an accommodation.

Consent to Bill

Child Name

First Last

Date of Birth

Gender

Female

Male

Insured Name

First Last

Date of Birth

Phone Number

Relationship to child

Address

Street Address Address Line 2 City State ZIP Code

Primary Insurance Carrier

First Last

Date of Birth

Phone Number

Member Number

Plan Name

Group Number

Effective Date

Secondary Insurance Carrier

First Last

Phone Number

Member Number

Group Number

Plan Name

Effective Date

Referring Physician

First Last

Phone

Primary Care Physician

First Last

Today's Date

Name of Parent or Guardian of Insured

First Last

Signature of Parent or Guardian of Insured

Notice of Privacy Practices

Today's Date

Patient or Personal Representative Name

First Last

Relationship to Patient

Patient or Personal Representative Signature

Responsibility of All Parties

Roles and Responsibilities

1. Client / Guardian Responsibilities

Provide accurate and timely information relevant to care or services.
Actively participate in treatment planning and service decisions.
Maintain open communication with providers.
Adhere to agreed-upon schedules and notify of cancellations in advance.
Respect staff and other clients’ rights and confidentiality.

2. Service Provider Responsibilities

Deliver services in a professional, ethical, and client-centered manner.
Maintain appropriate licensure, certification, and ongoing professional development.
Communicate clearly regarding treatment goals, methods, and progress.
Ensure client confidentiality and informed consent.
Respond promptly to client concerns and emergencies within the scope of practice.

3. Agency / Organization Responsibilities

Support service providers through training, supervision, and resources.
Uphold compliance with legal, ethical, and funding requirements.
Monitor quality assurance and address complaints or concerns efficiently.
Maintain accurate records and documentation.
Foster a safe, inclusive, and respectful environment for all.

Demographics

Child's Full Name

First Last

Date of Birth

Gender

Female

Male

Parent/Guardian Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Cell Phone

Work Phone

Email Address

Insurance Information

Primary Insurance

Phone Number

Insurer's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Subscriber Name

First Last

Subscriber's Date of Birth

Policy Number

Group Name

Group Number

Deductible

Upload copy of primary insurance card

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Is there secondary insurance?

Yes

No

Secondary Insurance

Phone Number

Insurer's Address

Street Address Address Line 2 City State ZIP Code

Subscriber Name

First Last

Subscriber's Date

Policy Number

Group Name

Group Number

Deductible

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Medical History

Primary Diagnosis (if applicable)

Date of Most Recent Diagnosis

Name of Clinician

Prefix First Last

Other Diagnoses (if applicable)

Other Medical Concerns

Current Medications

Please list Prior Medications

Allergies

Restricted Diet

Yes

No

Explain the Restriction(s)

Please list your primary concerns for your child

Activities your child enjoys

Developmental History

Prenatal History (complications if known)

Birth Weight

Birth Length

Were there any presenting concerns at birth? (e.g., premature, distress, infection, etc)

Yes

No

Please explain the concerns

Developmental Milestones reached when (use chronological age years and months if possible) * note delays can refer to mileston chart as necessary

Sensorimotor (Fine Motor) Function and Motor Development (Gross Motor). *Were there any noted delays in childhood? (e.g., holding bottle, grasping toys, crawling, walking, etc).

Background Information

Family Hisotry of Disabilities, Psychiatrics (depression, or things like that) or related health conditions

Who lives in the home (including siblings/parents/pets, etc)

Does your child have friends? If so, what are their names? *NOTE if the child is able and would like to answer this question you should ask the child first and can include guardian if the child requires assistance.

Sexual History if Applicable (any client over 14 should be asked, if too young mark N/A

Yes

No

N/A

Does your family have specific religious affiliations you'd like to share?

Does the child have a cultural or ethnic affiliation that they would like to share?

Parent Occupation: Mom

Parent Occupation: Dad

Educational History (e.g., special education, early intervention services, etc)

Previous Social Skills Groups or other group related services

Are there any other services/community resources you are interested in learning more about that may benefit you and your family?

Upload Documents and Records

Multicultural Community Services of the Pioneer Valley, Inc.

ABA Program

Process for Dispute Resolution

Each person who receives services from Multicultural Community Services (MCS) has the right to voice concerns or grievances regarding treatment, quality of services provided, or lack of respect for property. Individuals are entitled to an investigation by the Agency without fear of reprisal, discrimination, or interruption of services.

Filing a Complaint

Individuals or family members may contact the ABA Program Director verbally or in writing.
There is no time limit on when a complaint can be made; however, MCS encourages prompt communication.
All ABA staff are informed of this procedure and will provide families with information on how to file a complaint.

Procedures

The individual or family member will first express their concerns verbally or in writing to the ABA Program Director.
The ABA Program Director will review the concern and, if necessary, meet with the individual or family to recommend a resolution.
If the concern remains unresolved, the individual or family will be asked to summarize the complaint in writing and submit it to the Executive Director (ED). Individuals may request accommodations to participate in this process.
Upon receipt of the written complaint, the ED will contact the individual or family within one week and recommend a solution.
If dissatisfaction remains, the complaint may be forwarded to the Board of Directors for final review. The Board will issue a final decision after reviewing all facts.

Additional Information

Information about this procedure will be shared during the intake process.
All complaints will be documented using the Complaint Tracking Form.
The ABA Program Director will conduct ongoing reviews and analyses of all complaints.
MCS will maintain written records of complaints and resolutions at: 260 Westfield Rd, Holyoke, MA 01040.
MCS will notify the participant’s insurance company of any unresolved complaints within five (5) business days.

External Reporting Options

Families may also file complaints directly with:

Please upload a copy of your child’s

Diagnostic Assessment

Most recent Physical Report

Individualized Education Plan (I.E.P)

Copy of Insurance Card

Upload Diagnostic Assessment

Accepted file types: jpg, png, pdf, Max. file size: 16 MB.

Upload Physical Report

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Upload IEP

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Upload Insurance Card

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