Behavioral Connections — 2026 Intake Packet

Welcome to the BC Family!

Dear Parent/Guardian,

Taking this step for your child takes courage, commitment, and love — and we want you to know that you have come to the right place. We understand that navigating a new diagnosis or seeking additional support can feel overwhelming, and we are honored that you are trusting Behavioral Connections to be part of your family's journey.

At Behavioral Connections, we are committed to providing individualized, intensive ABA services to children diagnosed with Autism Spectrum Disorder, Pervasive Developmental Disorder (PDD), and related disabilities. We use Applied Behavior Analysis (ABA) and Applied Verbal Behavior (AVB) — scientifically validated approaches delivered at our clinics, in your home, and in the community. Every program we build is unique to your child, designed around their strengths, their needs, and your family's goals.

We believe families are the most important part of any child's progress. That is why parent training is built directly into our model — not as a requirement, but as an opportunity. Parents and caregivers who participate in a minimum of 2 hours of parent training per month gain the tools, confidence, and strategies to support their child's growth every hour of every day, not just during sessions. Your Supervising BCBA will work closely with you to make this time meaningful and practical for your family. Your child will also be assigned a dedicated team of RBTs who deliver direct therapy under BCBA oversight. You may interact with more than one clinician — that is intentional, and it strengthens your child's program.

Enclosed is your intake packet. Please complete all forms as thoroughly as possible — the more we know about your child before services begin, the better prepared we are to build a strong, trusting relationship with them. Also enclosed is the Behavioral Connections Parent Handbook, which contains everything you need to know about our policies, your rights as a family, and what to expect from services. We encourage you to read it and bring any questions to your Building Administrator or Supervising BCBA at any time.

What Happens Next

1	Submit your completed packet. Return all signed forms along with your child's diagnostic report, physician prescription, and insurance cards.
2	Insurance authorization. Once your file is complete, we will submit for insurance authorization. This process typically takes 2–4 weeks or longer. We will keep you informed along the way.
3	We will call you. As soon as authorization is received, we will contact you to schedule your child's initial evaluation.
4	Evaluation, treatment plan, and services begin. Your child's BCBA will conduct an assessment, develop an individualized treatment plan with your input, and schedule the start of services.

For the safety of all clients, families, and staff, all BC locations have surveillance cameras at entrances and throughout our buildings.

Questions? We are here to help. Contact your nearest location:
Bridgewater: (508) 807-4996 | North Dartmouth: (508) 807-4997

Sincerely,

Team BC

BC-TALK.COM

Intake Packet

Thank you for selecting Behavioral Connections to help meet the needs of your child. We understand that some of these forms may be challenging and time-consuming. The more information we have, the better able we will be to assist you and your family. Please contact us at any time if you have questions.

This packet includes the following forms:

The following documents are required before we can begin the intake process:

Fully completed intake packet (all forms signed)
Diagnostic evaluation report
Dated prescription for ABA services from your child's primary physician or developmental specialist
IEP or IFSP (if applicable)
Photocopy of front and back of primary and secondary insurance cards
Copy of your child's most recent physical examination notes

Important: If we have a waitlist, we are unable to place your child on the list until your file is complete. All forms must be signed and returned to Behavioral Connections before the onset of services.

For Office Use Only

Date packet received
Received by (staff name)
File complete? (all required docs received)
Date placed on waitlist / scheduled for intake
Notes

Application for Behavior Services

Who referred you to us?
For clinic services, which location?	Bridgewater North Dartmouth

Patient Information

Patient's Full Name
Date of Birth
Address (Street, City, State, Zip)
Primary Diagnosis
Secondary Diagnosis
Age at Diagnosis
Date Diagnosis Given
Diagnosing Physician
Diagnosing Physician Phone
Diagnosing Physician Fax
Diagnostic Tool / Instrument Used (e.g., ADOS-2, DSM-5 clinical evaluation, CARS)
How was the client diagnosed?	Observation Parent Report Direct Testing

Guardian / Parent Information

Legal Guardian #1 — Full Name
Relationship to Client
Social Security Number (required for billing and collections)
Address (Street, City, State, Zip)
Home Phone
Work Phone
Cell Phone
Email Address
Occupation
Employer
Title

Legal Guardian #2 (if applicable)

Legal Guardian #2 — Full Name
Relationship to Client
Social Security Number (required for billing and collections)
Address (if different)
Home Phone
Work Phone
Cell Phone
Email Address
Legal Restrictions with Parents?
Who lives with the client? (Names of adults)
Other children in the home? (Name and age)

Parent / Guardian Signature

Date

Service Options

Please select the type(s) of therapy services you would like to receive. Please note that while we will attempt to provide the type of service you request, not all services may be available at the time of your request.

Clinic-Based Services
Social Skills Groups / Play Therapy
Home-Based Services
Community-Based Services
School-Based Services
Toilet Training Program
Parent Training / Family Training
VB-MAPP Assessment & Program Recommendations

Please note: Telehealth is not offered as a direct therapy service. Telehealth may be used for parent training sessions and, in limited circumstances, for consultation related to service disputes or continuation of care.

Preferred Service Location

If you are requesting home-based services, please provide your home address below. If clinic-based, please indicate your preferred location.

Home Address for Home-Based Services (Street, City, State, Zip)
Preferred Clinic Location (if clinic-based)	Bridgewater North Dartmouth

Please indicate the days and time blocks that work best for your schedule. Scheduling is subject to medical necessity and staff availability.

Time Block	Mon	Tue	Wed	Thu	Fri
8:00 / 8:30 am – 9:00 am
9:00 am – 3:30 pm
9:00 am – 4:00 pm
3:30 pm – 5:30 pm

The undersigned hereby acknowledge that the information contained in this application is accurate in all respects.

Parent / Guardian Signature

Date

Medical Background

Primary Care Physician

Physician Name & Practice
Address (City, State, Zip)
Phone
Fax
Date of Last Well Check
Medical Conditions
Past Surgeries
Allergies (food, medication, environmental)
Food allergies or dietary restrictions relevant to therapy (snacks used as reinforcers must avoid these)

Does your child have a seizure disorder? YES NO

If yes, describe:

Date of last seizure:

Specialist (if applicable)

Specialist Name & Practice
Address (City, State, Zip)
Phone
Fax
Date of Last Well Check

Medications

* Please notify your child's Supervising BCBA any time there is a change in medication or dosage.

Medication Name	Start Date	Dosage	Used to Treat	Prescribing Doctor

Additional Medical Information

Special Diet?	YES NO
Describe:
Hearing Problems?	YES NO
Describe:
Visual Impairment?	YES NO
Describe:
Does your child have an EpiPen?	YES NO
If yes, why does your child require an EpiPen?

Emergency Contacts

* Please note: we contact parents / guardians first before emergency contacts.

Emergency Contact 1 — Name
Relationship to Client
Phone Number
Address (Street, City, Zip)
Emergency Contact 2 — Name
Relationship to Client
Phone Number
Address (Street, City, Zip)

Behavior Survey

Please answer the following questions about your child's behavior. This information helps our team prepare before your child's initial assessment.

Prior ABA History

Has your child previously received ABA therapy? YES NO

If yes, name of prior ABA provider(s)
Approximate dates of prior ABA services
Why did services end?
Were there any concerns about prior services we should know about?

Sleep, Feeding, and Toileting

This information helps our team understand your child's daily routines and identify areas that may be relevant to treatment planning.

Typical sleep schedule (bedtime / wake time)
Any significant sleep concerns (e.g., difficulty falling asleep, night waking, unusual sleep behaviors)?

Does your child have any feeding challenges (e.g., food selectivity, refusal, texture sensitivities)? YES NO

If yes, describe:

Is your child currently toilet trained? YES NO

If no or partially, describe current toileting status and any prior training attempts:

Behavioral Checklist

Physical Stereotypy	YES	NO
Does your child flap his/her hands or arms?
Does your child appear to look at fingers in a repetitive or stereotypic way?
Does your child look out of the side of his/her eyes?
Does your child walk on his/her toes?
Does your child rock (sit and rock back and forth)?
Verbal Stereotypy	YES	NO
Immediate echolalia — repeats what is said or heard right away?
Delayed echolalia — repeats phrases heard earlier at a later time?
Hums or makes vocal sounds to self inappropriately?
Screams or yells inappropriately?
Perseveration	YES	NO
Does your child get stuck on a topic?
Does your child become obsessive about specific people?
Does your child become obsessive about specific objects?
Transitions & Routines	YES	NO
Does your child have trouble with sudden, unexpected changes?
Does your child have trouble with changes they are warned about in advance?
Does your child fear specific objects, animals, places, or people?

If yes, please describe the fear(s):

Tantrums / Aggression / Self-Injury

Does your child have tantrums or aggressive behaviors that need to be addressed? YES NO

If yes, please describe the behavior(s), frequency, and typical triggers:

Does your child engage in self-injurious behavior (e.g., head-hitting, biting self, skin-picking)? YES NO

If yes, please describe:

Elopement History & Safety

Elopement refers to a child leaving a safe, supervised area without permission. Completing this section helps us develop an individualized elopement prevention plan if needed.

Has your child ever left a supervised area without permission (elopement)? YES NO

If yes, describe the most recent incident (where, when, what triggered it):

Does your child attempt to elope in specific situations (e.g., transitions, denied access to preferred items)? YES NO

If yes, describe the typical situations:

Does your child's school or other provider have an elopement prevention plan in place? YES NO

If yes, please describe the strategies used:

Are there environmental safeguards in place at home (e.g., door alarms, gates, window locks)? YES NO

If yes, describe:

Current elopement risk? (1 = low, 5 = very high)

Does your child use a GPS tracking device or wearable location monitor? YES NO

If yes, please describe the device and how it is used:

Skill Level

The information below helps our team prepare for your child's initial assessment.

Communication — indicate if vocal, sign, or picture-based
Does your child follow one-step instructions? (e.g., "go get your coat" → child gets coat)
How many words does your child use? (e.g., car, mom, Elmo, nose, up, more)

Functional Communication Profile

This section helps our clinical team understand how your child currently communicates before the initial assessment. Please be as specific as possible — there are no right or wrong answers.

Primary Communication Modality

Vocal / verbal speech
Augmentative and Alternative Communication (AAC) device — please specify below
Picture Exchange Communication System (PECS)
American Sign Language (ASL) or other sign system
Gestures (pointing, reaching, leading)
Written communication
Other — please describe below

If AAC device, what device/app does your child use?
If other, please describe:

Communication Details

How many words or phrases does your child use consistently? (approximate number)
What does your child typically communicate? (e.g., requests, protests, greetings, comments)
How does your child communicate "yes" or agreement?
How does your child communicate "no" or refusal?
How does your child communicate that they need a break or are overwhelmed?
Are there communication strategies that work particularly well with your child?
Are there communication strategies that do NOT work well or cause distress?

Prior Restrictive Practice History

Behavioral Connections does not use restraint or seclusion in any of our programs (see Section 9 of the Parent Handbook). However, it is important for our clinical team to know if your child has been exposed to these practices by other providers, as this may affect their response to treatment.

Has your child ever been physically restrained by a provider, school, or other service? YES NO

If yes, describe the circumstances and approximate dates:

Has your child ever been placed in seclusion (isolated in a room or space against their will) by a provider or school? YES NO

If yes, describe the circumstances and approximate dates:

Has your child ever been subject to any aversive or punitive procedure by a provider (e.g., use of sprays, loud sounds, or other unpleasant stimuli as consequences)? YES NO

If yes, describe:

Is there a current behavior support plan in place at your child's school that includes any restrictive procedures? YES NO

If yes, please describe and attach a copy if available:

Crisis and Safety Baseline Screen

The following questions help our clinical team understand your child's safety history and prepare appropriate supports before services begin. This is not a risk assessment — it is a baseline screen to ensure our team is properly informed and equipped from day one.

Emergency History

Has 911 or emergency services ever been called because of your child's behavior? YES NO

If yes, briefly describe the circumstances:

Has your child ever been hospitalized (psychiatric or medical) related to a behavioral episode? YES NO

If yes, when and where:

Has your child ever been seen in an emergency department for a behavioral crisis? YES NO

If yes, when and where:

Self-Injurious and Dangerous Behavior

Does your child engage in self-injurious behavior (e.g., head banging, self-biting, scratching)? YES NO

If yes, describe the behavior and how often it occurs:

Has your child ever injured a family member, caregiver, or peer during a behavioral episode? YES NO

If yes, describe:

Does your child have any behaviors that you consider dangerous or that require immediate intervention? YES NO

If yes, describe:

Existing Crisis Planning

Does your child currently have a crisis plan developed by another provider or school? YES NO

If yes, which provider developed it and do you have a copy?

Are there specific triggers that reliably precede a crisis episode for your child? YES NO

If yes, please list them:

Are there specific de-escalation strategies that reliably help your child during a crisis? YES NO

If yes, please describe:

Is there anything else you would like us to know about your child's safety history before services begin?

School and Provider History

Did the client receive Early Intervention services? YES NO

If yes, agency name:

Current School

School Name
Address (Street, City, State, Zip)
Teacher / Contact Name
Grade
Phone Number
Email

Occupational Therapy

Agency Name
Therapist Name
Address
Phone
Email

Speech-Language Therapy

Agency Name
Therapist Name
Address
Phone
Email

Psychologist / LCSW

Agency Name
Therapist Name
Address
Phone
Email

Other Provider

Agency / Provider Name
Contact Name
Address
Phone
Email

By signing below, you give Behavioral Connections consent to release and receive information regarding the client, including medical and non-medical records, for the purposes of coordinating care. This consent remains in effect until services end or you revoke it in writing.

Parent / Guardian Signature

Date

Reinforcement Assessment Form

Prior to beginning services, it is important to identify your child's motivators and potential reinforcers. Many children are highly specific in their preferences. Please provide as much detail as possible. Use a scale of 1–5 (1 = most preferred) for each category where applicable.

What are your child's media preferences?

Other videos, movies, or shows your child likes:

What are your child's favorite snacks and foods?

What are your child's favorite activities and toys?

Are there any items your child strongly dislikes or should NOT be used? Please explain:

Screen Time and Technology

Does your family have screen time rules or restrictions we should be aware of? (e.g., no screens before school, limited daily minutes, approved apps/shows only)
Are there specific devices, apps, or videos your child is NOT allowed to access?
May BC staff use a tablet or screen-based content as a reinforcer during sessions?	Yes No Yes, with restrictions (describe above)

Known Aversives and Non-Preferred Items

Identifying what your child dislikes or finds distressing is just as important as knowing what they enjoy. This helps our team plan sessions safely and avoid unnecessary distress.

Foods or drinks your child refuses or reacts negatively to
Sensory experiences your child dislikes (e.g., sounds, textures, lights, smells)
Activities or situations your child strongly avoids
People, places, or objects that cause distress or fear
Any latex allergy or sensitivity to materials (e.g., certain plastics, fabrics, art supplies)?

Health Insurance Information

Primary Insurance

Primary Insurance Name
Member ID #
Primary Coverage Start Date
Subscriber's Date of Birth
Subscriber's Full Name
Subscriber's Relationship to Client
Subscriber's Address

Secondary Insurance (if applicable)

Secondary Insurance Name
Member ID #
Secondary Coverage Start Date
Subscriber's Date of Birth
Subscriber's Full Name
Subscriber's Relationship to Client

Please provide photocopies of the front and back of all insurance cards.

Parent / Guardian Financial Agreement

Applied Behavior Analysis Services

Client Information

Client Name (Child)
Date of Birth
Parent / Legal Guardian Name
Relationship to Client
Phone Number
Email Address
Primary Insurance Carrier
Policy / Member ID
Secondary Insurance (if applicable)
Effective Date of Current Policy

Section 11.1 — Insurance Updates

To avoid any interruption in your child's services, you are required to notify your building administrator immediately if your health insurance is going to change. Behavioral Connections must receive your new insurance details before the effective date of your new policy so that the pre-authorization process can begin. Failure to provide this information in advance may result in a temporary pause in services until new authorization is approved.

I understand I must notify my building administrator immediately of any upcoming insurance changes and provide new insurance details before the effective date of the new policy.
I understand that if new insurance information is not received in time, my child's services may be paused until a new authorization is obtained.

Section 11.2 — Billing for Co-Pays and Deductibles

Co-pays and deductibles will be billed directly to you or any secondary insurance on file. Invoices are issued monthly by default; weekly invoices are available upon request. As the parent or legal guardian, you are responsible for all co-pays, deductibles, cost share, and co-insurance amounts as determined by your agreement with your insurance carrier. Co-pays are billed once per day, regardless of the number of sessions your child receives that day.

I understand that co-pays and deductibles are my responsibility as the parent/legal guardian, as outlined in my agreement with my insurance carrier.
I understand that co-pays are billed once per day, regardless of the number of sessions my child has that day.
I understand that cost share and co-insurance (if applicable under my plan) are also my responsibility, and I will contact my insurance carrier to confirm my coverage details.
I understand that client invoices are generated monthly for any outstanding co-pays, deductibles, or client-responsibility balances. The first invoice is sent once the balance becomes my responsibility after insurance processes the claim. If no payment is received, a second invoice will be sent after 30 days and a third invoice after an additional 30 days.
I understand that beginning with the second invoice, a payment plan will be offered, allowing me to set up monthly installments to keep my account in good standing. To request a payment plan, I will contact Tammy St. Michel, Director of Billing, Revenue & Administrative Operations, in writing at my building's main office.
I understand that if my balance remains unpaid after multiple monthly statements (typically 90–120 days), a final notice will be issued indicating that the account may be referred to a collections agency if no response is received. Accounts that remain unresolved after two (2) years may be written off as bad debt.

Acceptable Payment Methods: Behavioral Connections accepts Check, Cash, ACH / Bank Transfer, and Money Order. Payments should be made payable to Behavioral Connections and submitted to your building administrator or the main office. Credit and debit cards are not accepted.

I understand that accepted payment methods are: Check, Cash, ACH / Bank Transfer, and Money Order.

Section 11.3 — Flexible Spending Accounts (FSA)

Flexible Spending Accounts (FSAs) use pre-tax dollars and can be applied toward co-pays and deductibles, helping to reduce your out-of-pocket costs. Behavioral Connections can assist you in estimating your annual FSA contribution if requested.

I am interested in receiving assistance estimating my FSA contribution for the year. Please have a staff member contact me.

By signing below, I confirm that I have read, understand, and agree to the financial policies outlined in this agreement.

Parent / Legal Guardian Signature

Date

Printed Name

Building / Location

For Office Use Only

Received By
Date Received
File / Chart #

Informed Consent for ABA Services

Patient's Full Name
Date of Birth

STATEMENT OF AUTHORITY TO CONSENT: I certify that I have the legal authority to consent to assessment, release of information, and all legal matters involving the above-named client. Upon request, I will provide Behavioral Connections with proper legal documentation to support this claim. If my status as legal guardian changes, I will immediately notify Behavioral Connections and provide the name, address, and phone number of any person who assumes guardianship.

CONSENT TO EVALUATE: I consent for Behavioral Connections to conduct an initial skills assessment of the above-named client using standardized and naturalistic assessment methods appropriate to their age and presentation.

CONSENT TO TREAT: I consent for ABA therapy services to be provided to the above-named client by Behavioral Connections and its staff. I understand that procedures will include manipulating antecedents and consequences to produce improvements in behavior, using positive reinforcement, and teaching functional replacement behaviors. Physical prompting and manual guidance may be used as part of the teaching process — this means a therapist may gently guide your child's hands, body, or movements to help them learn a skill, and prompts are gradually faded as your child becomes more independent. I understand that at the start of treatment, behavior may temporarily get worse (extinction burst) or generalize across settings (behavioral contrast), and that my BCBA will explain this process to me.

ACKNOWLEDGMENT OF TREATMENT PLAN: I acknowledge that prior to the start of services and at each reauthorization, I will be provided with my child's Individualized Treatment Plan, including all treatment goals and intervention strategies, and that my written consent is required before treatment begins or is substantially changed.

TELEHEALTH: I understand that Behavioral Connections does not provide direct ABA therapy via telehealth. Telehealth may be used in limited circumstances for parent training sessions and for consultations related to service continuation or dispute resolution, as described in Section 24 of the Parent Handbook. I understand that I may request an in-person meeting at any time.

RIGHT TO REVOKE: I understand that I may revoke this consent at any time in writing. Revocation will not affect actions already taken. A copy of this consent is as valid as the original.

The witness must be a Behavioral Connections staff member — not a family member or other client.

Parent / Guardian Signature

Date

BC Staff Witness Signature

Date

Parent / Guardian Signature (2nd guardian, if applicable)

Date

BC Staff Witness Signature

Date

Photo / Video and Data Release Form

Please read this form carefully. It covers three distinct areas: (1) the use of photographs and video recordings taken during therapy, (2) building surveillance cameras, and (3) the use of clinical data collected during your child's sessions. Each section requires a separate signature or acknowledgment.

Section A — Photography and Video Recording During Sessions

I hereby grant Behavioral Connections permission to photograph and/or video record my child during therapy sessions, without payment or any other compensation.

I certify that I am the parent or legal guardian of the client named below, that I am 18 years of age or older, and that I am competent to provide this consent on my child's behalf. I have read this form and fully understand its contents.

Permitted uses of photos and video recordings:

Staff training, clinical supervision, and BCBA oversight of your child's program
Internal quality improvement and clinical review
BACB credentialing and compliance purposes

Any use beyond the above — including marketing, social media, external presentations, or sharing with outside organizations — requires separate written consent from the parent or legal guardian prior to use. You will be contacted and given the opportunity to approve or decline any such use before it occurs.

This authorization is reviewed annually and at each reauthorization period. You may revoke it at any time by notifying your Building Administrator in writing.

Print Name of Client
Print Name of Parent / Guardian

Signature of Parent / Guardian

Date

I do NOT consent to photography or video recording of my child for any purpose other than direct clinical recordkeeping.

Parent / Guardian Signature if declining

Date

Section B — Building Surveillance Cameras

All Behavioral Connections locations are equipped with surveillance cameras at building entrances and throughout interior common areas and therapy spaces. These cameras operate continuously during business hours for the safety and security of all clients, families, and staff.

Surveillance footage is used solely for safety, security, and, where clinically appropriate, staff supervision and training. Footage is stored securely and is not shared with outside parties except as required by law or in response to a safety incident.

By enrolling your child in services at Behavioral Connections, you acknowledge that your child and accompanying family members may appear on surveillance footage during visits to any BC location. This is not optional — cameras are a permanent feature of all BC facilities.

I acknowledge that Behavioral Connections facilities use surveillance cameras and that my child and I may appear on recorded footage during visits.

Parent / Guardian Signature

Date

Section C — Clinical Data

During the course of your child's ABA services, Behavioral Connections collects clinical data including session notes, skill acquisition data, behavior data, and assessment results. This data is your child's protected health information (PHI) and is governed by our HIPAA Notice of Privacy Practices.

In addition to direct use in your child's treatment, de-identified or aggregated clinical data (from which all personal identifiers have been removed) may be used for staff training and clinical supervision, internal quality improvement and program evaluation, and BACB credentialing and supervision compliance. De-identified data cannot be traced back to your child and is not considered PHI under HIPAA.

I acknowledge that de-identified clinical data may be used for internal training, quality improvement, and credentialing purposes as described above.

Parent / Guardian Signature

Date

HIPAA Notice of Privacy Practices — Acknowledgment

Behavioral Connections complies fully with the Health Insurance Portability and Accountability Act (HIPAA) and applicable Massachusetts data security laws. Under HIPAA, you have the following rights regarding your child's protected health information (PHI):

Right to Access: You have the right to inspect and obtain copies of your child's records. Written requests are processed within 30 days and directed to our Privacy Officer.
Right to Amend: You have the right to request corrections to your child's health information. We will respond in writing within 60 days.
Right to Request Restrictions: You have the right to request limits on how we use or share your child's information. We must honor requests to restrict disclosure to a health plan for services paid entirely out-of-pocket.
Right to an Accounting of Disclosures: You have the right to receive a list of certain disclosures we have made of your child's PHI going back up to six years (excluding disclosures for treatment, payment, or operations).
Right to Confidential Communications: You have the right to request that we contact you in a specific way or at a specific location. We will accommodate reasonable requests.
Right to Notice: You have the right to receive a written copy of our Notice of Privacy Practices (NPP) at any time, even if you previously received it electronically.
Right to Breach Notification: You have the right to be notified, within 60 days of discovery, if your child's unsecured PHI is breached.
Right to Restrict Electronic Access: You may request limitations on electronic access to or transmission of your child's health information where technically feasible.
Right to Complain: You have the right to file a complaint with Behavioral Connections or with the U.S. Department of Health and Human Services, Office for Civil Rights (www.hhs.gov/ocr | 1-800-368-1019). You will not be penalized for filing a complaint.

Our full Notice of Privacy Practices (effective March 19, 2026) is provided with this packet and is available at both clinic locations and upon request. To contact our Privacy Officer: Vaughn Maxson | [email protected] | Bridgewater (508) 807-4996 | North Dartmouth (508) 807-4997.

By signing below, I acknowledge that I have received and had the opportunity to review the Behavioral Connections Notice of Privacy Practices (effective March 19, 2026).

Name of Client
Name of Parent / Guardian

Signature of Parent / Guardian

Date

Authorization for Release of Information

Patient's Full Name
Date of Birth
Patient's Address

I understand that this authorization is voluntary. I understand that my child's health information may be protected by federal and state privacy laws, including HIPAA (45 CFR Parts 160 and 164) and applicable Massachusetts law. I understand that I may revoke this authorization at any time by notifying Behavioral Connections in writing; however, revocation will not affect disclosures already made. A copy of this authorization is as valid as the original.

I authorize Behavioral Connections to receive from and/or disclose health information for the client named above to the following providers (check all that apply and provide contact information):

Primary Care Physician (PCP)
PCP Phone:
PCP Fax:
PCP Email:
Neurologist — Phone / Fax / Email:
Address:
Developmental / Behavioral Pediatrician — Phone / Fax / Email:
Address:
Psychiatrist / Psychologist — Phone / Fax / Email:
Address:
Neuro-Psychologist — Phone / Fax / Email:
Address:
Speech-Language Pathologist — Phone / Fax / Email:
Address:
Occupational Therapist (OT) — Phone / Fax / Email:
Address:
Teacher / School District — Phone / Fax / Email:
Address:
Other Provider — Phone / Fax / Email:
Address:

Type(s) of information authorized to be shared (check all that apply):

The purpose of this authorization is to allow the appropriate management and coordination of treatment and services.

This authorization will remain in effect until: (1) the client no longer receives services from Behavioral Connections, or (2) the parent/guardian revokes it in writing, or (3) the optional expiration date specified below, whichever comes first.

Optional: I would like this authorization to expire on (leave blank if services-end default is preferred)

Parent / Guardian Printed Name

Today's Date

Parent / Guardian Signature

Relationship to Client

Phone Number

Parent / Guardian Address

I do NOT give Behavioral Connections permission to share my child's information with outside providers at this time.

Parent Signature

Date

Client and Family Rights Statement

Behavioral Connections is committed to delivering services that are ethical, individualized, and respectful of the dignity of every client and family. The following rights are guaranteed to all clients and families enrolled in BC services. Please read each right, and sign below to confirm you have received and understood this statement.

Right to Participate in Treatment Planning

You have the right to be an active participant in your child's treatment. You will be provided with your child's Individualized Treatment Plan before services begin and at each reauthorization, and your written consent is required before treatment begins or is substantially changed.

Right to Refuse Specific Interventions

You have the right to refuse any specific treatment procedure or intervention at any time. Your BCBA will explain the clinical rationale for proposed interventions, and you may decline any procedure without penalty to your child's enrollment.

Right to a Second Opinion

You have the right to seek a second clinical opinion about your child's diagnosis, treatment plan, or any recommended intervention. BC staff will not discourage you from seeking outside consultation.

Right to Access Records

You have the right to read, request copies of, and receive a summary of your child's clinical records in accordance with HIPAA. Requests are processed within 30 days.

Right to Confidentiality

Your child's protected health information will not be shared with outside parties without your written authorization, except as required by law. See our HIPAA Notice of Privacy Practices for full details.

Right to File a Grievance

You have the right to file a complaint or grievance about your child's services, the behavior of any BC staff member, or any aspect of your experience without fear of retaliation. See the Grievance Procedure Summary in this packet for instructions.

Right to Culturally Responsive Services

You have the right to services that are sensitive to your family's cultural background, language, and values. You may request interpreter services or translated materials at any time at no cost.

Right to be Treated with Dignity

Your child has the right to be treated with respect and dignity at all times. Behavioral Connections staff are prohibited from using demeaning language, punitive procedures, or any form of humiliation as part of treatment or classroom management.

Right to Know Staff Qualifications

You have the right to request information about the qualifications and credentials of any BC staff member working with your child, including their level of supervision.

Right to Transition Planning

When services are ending or transitioning, you have the right to a planned, collaborative discharge process that includes referrals, transition documentation, and sufficient notice.

By signing below, I confirm that I have received, read, and understood the Client and Family Rights Statement above.

Client's Full Name
Date of Birth

Parent / Guardian Signature

Date

Grievance Procedure Summary

Behavioral Connections takes all complaints seriously. The following is a plain-language summary of how to file a grievance. The full Grievance Policy is in Section 17 of the Parent Handbook.

Step 1 — Talk to Your Building Administrator

For most concerns, the fastest resolution comes from speaking directly with your Building Administrator. They are your primary point of contact for scheduling, billing, staff concerns, and day-to-day service issues. You can reach them by phone or in person at your BC location during business hours.

Step 2 — Submit a Written Complaint

If your concern is not resolved informally, you may submit a written complaint to your Building Administrator or to the Clinical Director. Written complaints may be submitted by email, mail, or in person. Your complaint should describe: (1) what happened, (2) when it happened, and (3) what resolution you are seeking.

Step 3 — Formal Review

Behavioral Connections will acknowledge receipt of your written complaint within 5 business days and will conduct a formal review. You will receive a written response within 30 calendar days of the date your complaint was received.

Step 4 — External Options

If your concern is not resolved to your satisfaction through BC's internal process, you have the right to contact your insurance carrier's member services department, the Massachusetts Department of Public Health, or the Massachusetts Behavioral Health Partnership (MBHP) if applicable.

No Retaliation: Behavioral Connections will never reduce, alter, or terminate your child's services in retaliation for filing a grievance. If you believe retaliation has occurred, please escalate immediately to the Clinical Director or contact your insurer.

By signing below, I confirm that I have received and read the Grievance Procedure Summary and understand how to file a complaint if needed.

Parent / Guardian Signature

Date

Emergency Action Plan

This form ensures that BC staff are prepared to respond appropriately in the event of a medical emergency during your child's session. Please complete all sections. This plan will be kept in your child's clinical file and reviewed at each reauthorization.

Emergency Contacts

Primary Emergency Contact Name
Relationship to Client
Primary Emergency Contact Phone (cell)
Primary Emergency Contact Phone (alt)
Secondary Emergency Contact Name
Relationship to Client
Secondary Emergency Contact Phone

Medical Emergency Protocols

Does your child have a seizure disorder? YES NO

If yes, describe the type of seizures:

Seizure response protocol (duration before calling 911, positioning, medication):

Does your child carry or require an EpiPen or other emergency medication? YES NO

If yes, what is it and who administers it?

Does your child have a cardiac condition, respiratory condition, or any other medical condition that could require emergency intervention? YES NO

If yes, describe and list the response protocol:

Preferred Hospital

Preferred hospital or medical facility in the event of an emergency
Any hospitals or facilities your child should NOT be taken to (and reason)
Child's Blood Type (if known)

General Emergency Instructions

Is there anything else BC staff should know to respond appropriately in an emergency?

By signing below, I confirm that the information above is accurate and I authorize BC staff to contact emergency services on my child's behalf in the event of a medical emergency.

Parent / Guardian Signature

Date

Discharge and Transition Planning Acknowledgment

Behavioral Connections is committed to supporting your child's long-term success, which includes planning thoughtfully for transitions out of ABA services. The following describes the circumstances under which a discharge review may be initiated and how BC will support your family through any transition. This information is described in full in Section 18 of the Parent Handbook.

Policy Statement	Initial
I understand that discharge from BC services may be initiated when treatment goals have been met, when my child's clinical needs exceed the scope of BC's services, when my child no longer meets insurance criteria for ABA, or when services are no longer clinically appropriate.
I understand that chronic cancellations, extended absences without communication, or loss of insurance authorization may trigger a discharge review. BC will make reasonable efforts to contact me before initiating a discharge.
I understand that if I choose to voluntarily discontinue services, I am asked to provide at least two weeks' notice so BC can prepare appropriate transition documentation for my child's next provider or school.
I understand that BC will provide a written discharge summary at the close of services, including a summary of goals addressed, progress made, and recommendations for next steps.
I understand that BC will make reasonable efforts to provide referrals to other providers when services end and that I am not obligated to accept any specific referral.
I understand that in cases of immediate safety risk to staff or other clients, BC reserves the right to suspend or terminate services with shorter notice, and that this decision will be documented and communicated to me in writing.

By signing below, I confirm that I have read and understood the discharge and transition planning information above and in Section 18 of the Parent Handbook.

Client's Full Name
Date of Birth

Parent / Guardian Signature

Date

Cultural and Linguistics Survey

Behavioral Connections is committed to providing culturally responsive, individualized care. The information you share here helps our team better understand and respect your family's background, language needs, and preferences. All responses are voluntary and will be kept confidential as part of your child's clinical record.

Language Access: If your preferred language is not English, you have the right to request interpreter services and translated materials at no cost. Please notify your Building Administrator as early as possible so we can arrange appropriate support before services begin. See Section 25 of the Parent Handbook for our full Language Access Policy.

Cancellation and Attendance Policy Acknowledgment

Consistent attendance is essential to your child's progress in ABA therapy. The following policies apply to all Behavioral Connections clients and are described in full in Section 16 of the Parent Handbook. Please read each item carefully and initial the line provided.

Policy Statement	Initial
I understand that cancellations must be made at least 24 hours in advance by contacting my Building Administrator directly. Same-day cancellations and no-shows may be counted against my child's attendance record.
I understand that if my child misses more than two consecutive sessions without communication, Behavioral Connections may contact me to discuss continuity of care and, in some cases, may need to place my child's slot on hold or initiate a discharge review.
I understand that chronic cancellations or no-shows may affect my child's authorization status, as insurers require documentation of active participation to continue funding services.
I understand that sessions cancelled due to severe weather or building closures declared by Behavioral Connections will not count against my child's attendance record. I will monitor BC communications (email, phone) for closure notifications.
I understand that if I arrive more than 15 minutes late for a session without prior notice, the session may be shortened or rescheduled at the discretion of the clinical team.
I understand that scheduling changes must be requested through my Building Administrator and are subject to staff availability. I cannot unilaterally change my child's schedule without going through the scheduling process.

By signing below, I confirm that I have read and understood the Cancellation and Attendance Policy as described above and in Section 16 of the Parent Handbook.

Client's Full Name
Date of Birth

Parent / Guardian Signature

Date

Home-Based Services Safety Agreement

This form applies to families receiving home-based ABA services. If your child receives clinic-based services only, you do not need to complete this form. Please write "N/A" across the signature line and return it with your packet.

To ensure the safety of your child, our staff, and all household members during home-based sessions, Behavioral Connections requires that the following conditions be maintained. These expectations are described in Section 5 of the Parent Handbook.

Policy Statement	Initial
A responsible adult (18 years or older) will be present in the home at all times during sessions. I understand that staff cannot conduct a session if no responsible adult is present.
I will provide a reasonably quiet, dedicated space for therapy sessions — free from excessive noise, interruptions, and distractions that would interfere with my child's ability to participate.
All pets will be secured away from the therapy space during sessions. I understand that staff have the right to request that a pet be removed or secured if it poses a safety concern.
I will ensure that all firearms, weapons, medications, cleaning supplies, and any other hazardous materials are stored securely and out of reach of my child before each session.
I will not ask Behavioral Connections staff to perform any tasks unrelated to therapy (e.g., childcare for siblings, household tasks, personal errands) during sessions.
I understand that staff may not transport my child in a personal vehicle or accompany my child to locations not previously authorized in the treatment plan.
I will notify my Supervising BCBA of any changes to the home environment that may affect session safety — including new household members, construction, or significant changes in the home's physical layout.
I understand that if a BC staff member determines that the home environment is unsafe on a given day, they have the authority to end the session and report the concern to their supervisor. I will not penalize or retaliate against staff for exercising this judgment.

By signing below, I agree to maintain a safe home environment for Behavioral Connections sessions and to comply with the home-based services guidelines described in Section 5 of the Parent Handbook.

Client's Full Name
Date of Birth

Parent / Guardian Signature

Date

Social Media and Photography Policy Acknowledgment

Behavioral Connections is committed to protecting the privacy and dignity of all clients, families, and staff. The following policy applies to all families enrolled in BC services and is described in full in Section 15 of the Parent Handbook. Please read each item and initial the line provided.

Policy Statement	Initial
I understand that I may not photograph, video record, or audio record any Behavioral Connections staff member without their explicit, prior verbal or written consent.
I understand that I may not photograph, video record, or audio record any other client or family at a BC facility at any time, even incidentally.
I understand that I may not post, share, or publish any image, video, or audio recording on social media or other public platforms that identifies, depicts, or could be used to identify any BC staff member, other client, or other family without their explicit consent.
I understand that posting negative, defamatory, or false statements about BC staff, other clients, or their families on social media or public platforms is a violation of this policy and may affect my child's enrollment.
I understand that Behavioral Connections' social media and photography policy does not restrict my ability to discuss my own child's progress or share information about my own family's experience, provided I do not identify or disclose information about other clients, families, or staff.
I understand that the building surveillance cameras described in the Photo/Video & Data Release Form are separate from personal recording devices and that the policies governing them are described in Section 15 of the Parent Handbook.

By signing below, I confirm that I have read and understood the Social Media and Photography Policy as described above and in Section 15 of the Parent Handbook.

Client's Full Name
Date of Birth

Parent / Guardian Signature

Date

Treatment Preferences and Family Values

ABA therapy is most effective when it is built around your family's goals, values, and definition of success. Your answers here will be shared directly with your child's BCBA and will inform how treatment goals are developed and prioritized. There are no right or wrong answers — please be as open and specific as you feel comfortable being.

Goals and Priorities

Where do you hope to see your child one year from now?
What is the most important skill you would like your child to be able to do that they cannot do now?
What behavioral or communication challenges most affect your family's daily life right now?

Family and Household Context

Are there other children in the home? If so, please list their names and ages.
Are any siblings or household members also receiving therapeutic or special education services? If yes, please describe.
Are there any household dynamics (e.g., new baby, recent move, shared bedroom, custody schedule) that may affect scheduling or your child's ability to participate in home-based sessions?

Family Values and Cultural Considerations

Are there any values or beliefs about child-rearing, disability, or behavior that you would like the clinical team to be aware of when planning treatment?
Are there any specific approaches, activities, or materials that should NOT be used in your child's therapy for any reason (personal, religious, cultural, or due to prior negative experience)?
Are there any important dates, holidays, or religious observances the clinical team should work around when scheduling sessions?

Your Role in Treatment

How would you like to be involved in your child's sessions? (e.g., actively participating, observing, receiving written updates, separate parent training)
How do you prefer to communicate with your child's BCBA? (e.g., email, phone call, written notes, in-person meeting)
Is there anything else you would like the clinical team to know about your family, your child, or your hopes for this program?

Your responses will be reviewed by your child's assigned BCBA prior to the initial assessment. You will have the opportunity to revisit and update your preferences at each reauthorization period.

Parent Handbook Acknowledgment

You are welcome to take the Parent Handbook home to review before returning this signed form. Please sign and return this acknowledgment to your Building Administrator before or at your child's first session.

The Behavioral Connections Parent Handbook 2026 Edition contains important information about our policies, your rights, and what to expect from services. Please review the handbook in full before signing this acknowledgment.

I, the undersigned parent or legal guardian, acknowledge the following:

I have received and reviewed the Behavioral Connections Parent Handbook 2026 Edition.
I have had the opportunity to ask questions about any policies contained in the handbook, and my questions have been answered to my satisfaction.
I understand and agree to abide by the policies and expectations described in the handbook, including but not limited to: attendance and cancellation policies, parent training participation requirements, the technology and device use policy, the social media and photography policy, the safety policies, and the grievance procedures.
I understand that the handbook is updated periodically and that I will be notified of substantive changes. The most current version of the handbook supersedes all prior versions.
I understand that I may contact my Building Administrator or Supervising BCBA at any time if I have questions about any policy.

Patient's Full Name
Date of Birth

Parent / Guardian Printed Name

Date

Parent / Guardian Signature

Parent / Guardian Printed Name (2nd guardian, if applicable)

Date

Signature (2nd guardian)

Date

BC Staff Member / Witness Printed Name

Signature

Date

What is the primary language spoken in your home?

Does your child respond to and understand the primary language?	YES NO
Is there a secondary language spoken in your home?	YES NO
If yes, what is it?
Does your child respond to and understand the secondary language?	YES NO
Do you need an interpreter when meeting with Behavioral Connections staff?	YES NO
If yes, what language would you like the interpreter to speak?
Do you have any cultural or religious beliefs or preferences you would like us to know about?	YES NO
If yes, please explain:
Are there any cultural or religious accommodations you would like Behavioral Connections to provide?	YES NO
If yes, please explain:
Does your family observe any religious or cultural dietary restrictions that should be considered when selecting food reinforcers used during therapy? (e.g., halal, kosher, vegetarian, no pork, no beef)
Is there anything else about your family's heritage, ethnicity, or cultural background that you would like to share with our team?