Inspire Behavior Therapy & Consulting WELCOME!
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- Andrea Richards
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1 Inspire Behavior Therapy & Consulting Hours: By Appointment (Monday- Saturday) Staff Contact Information: Director Jennifer Kaut M.Ed. Founder/Behavior Analyst/Certified Equine Therapist (512) Behavior Therapists Pamela White M.Ed. BCBA Board Certified Behavior Analyst (215) Tarsah Dale Behavior Therapist (215) WELCOME! Equine Therapists Julie Biggs: Lead Therapeutic Riding Instructor/Certified Equine Learning Therapist (512) Tinker Reed: Therapeutic Riding Instructor/Certified Equine Learning Therapist (512) Questions/Concerns about Payment/Invoices/Sales Receipts: Contact: Shelley Hickman Parents- I am committed to bringing you quality programming and treatment for your child. Please feel free to contact me if you have ANY questions or concerns at anytime regarding their care while at Inspire Behavior. I am SO excited to see your children s wings open and fly with the tools we give them! Jennifer Kaut M.ED. Founder & Director of Inspire Behavior Therapy & Consulting
2 INSPIRE BEHAVIOR FEE S BEHAVIORAL SERVICES: LOCATED AT 921 W. NEW HOPE ROAD SUITE 405 CEDAR PARK, TX Sessions are 50 minutes in length. In Office- Individual Session/ABA - $65.00 per session. Travel Individual Session/ABA - $75.00 per session. (If more than 20 miles, then a.55/mile is charged after that) Travel Group Session - $45.00 per session Group Session -$ 35 per session 10% for payment in full on or before the 1 st session. Attendance of an ARD/School Consult- current rate is $75.00 per session. Reviewing of Paperwork/Report Fee/Phone Consult- $40 EQUINE SERVICES: LOCATED AT OPEN MY WORLD THERAPEUTIC RIDING CENTER: 1020 CR 270 LEANDER, TX Sessions are 60 minutes in length. Therapeutic Horseback Riding (requires at least 2 trained staff) $45 per session. To learn more about Open My World: visit their website
3 Inspire Behavior Therapy & Consulting NEW CLIENT REGISTRATION FORM CHILD s NAME: AGE: GRADE: School Attends: that you can be contacted at: Today s Date: PARENT/LEGAL GUARDIAN INFORMATION (PERSON RESPONSIBLE FOR PAYMENT) Last name: First: Middle: Mr. Miss Marital status (circle one) Mrs. Ms. Single / Mar / Div / Sep / Wid Is this your legal name? If not, what is your legal name? (Former name): Birth date: Age: Sex: Yes No / / M F Street address: Social Security no.: The best phone # to contact: ( ) P.O. box: City: State: ZIP Code: Occupation: Employer: Employer phone no.: ( ) Found Inspire Behavior through/referred to Inspire Behavior by (please check one box): Dr. Therapist Signs Family Friend Newspaper Ad Website Other
4 Inspire Behavior Therapy & Consulting Giving them wings to fly ~Please initial beside each that you have read and agree to each statement~ ~Confidentiality All information exchanged between client and therapist is kept confidential except for when the therapist deems there is threat or suspension of harm to another- were of we are bound by the law to report immediately. To allow for the best treatment, parents need to stay in the designated waiting areas while their children are in session or group. ~Attendance & Participation of Parent/Guardian~ Emergencies happen, but we cannot provide the best treatment for you or your child if they are not consistently present or if you are not able to come for the recommended time. Inspire Behavior reserves the right to terminate services when treatment for these reasons are not benefiting the client. ABA is designed for everyone who is involved directly involved with the child/teen or adult. Participation by parents is required. Participation in treatment may consist of following recommended behavior plans, taking data, certain homework or attending our workshops. ~Release of Information to School & or Another Healthcare Provider I give/do not give of Inspire Behavior permission to release information regarding my child through: Please Circle- phone, , reports, assessments, additional copies of notes/strategies used or ALL of THE ABOVE. Name of School: Name of Therapist(s):, Name of Doctors(s):,, ~Photographs/videos taken I give/do not give permission to have my child s photo/videos taken. For Educational/Behavioral uses: Yes or No To appear on photo gallery on website: Any Questions- please ask! ~Payment of Services Rendered After each appointment, payment is expected. No insurance billing is offered at this time. Credit Cards, Checks, Cash and PayPal online are accepted. If requested, you can receive a printed receipt for your payment. Receipt is sent through . No Overdue balances. Services will be terminated after a balance is 2 weeks late or after 2 unpaid sessions. Late fee of $35 is applied. You can be charged full price for failure to give a 24 hour cancellation notice. A $35 returned check will be collected. At any time, Inspire Behavior has the right to no longer accept checks from you. This includes a chargeback from card companies. Failure to make payments will be turned into a collection agency. If you are attending a group, payment may be per session, but you are still held liable for the full amount (12 sessions) if you are absent or stop attending before the 12 sessions are up. A 10% discount is given for payment in full by or at the 1 st session. Inspire Behavior has the right to cancel a group at anytime for lack of attendance, illness of attendees or any other extraneous issues that cause a significant break down in the weekly group dynamics deemed by Jennifer Kaut. ~Other Children who are not in Treatment Are welcome to come with you and wait~ We just ask that you not allow them to roam free without supervision for their safety. We also ask that they respect the other clients need for quietness. At the ranch, horses are only for clients. Children must be with therapists to be in these areas at the ranch. I have read the above statements. I understand and agree to them while working with Inspire Behavior Therapy & Consulting. Client/Parent/Guardian Date
5 Parent Fast Fact Sheet Basic Information Your child s name: Age DOB: Parent/Guardian s name: Best phone number: Best address to contact: School School they attend District this is in Is this a Public or Private school? Do they specialize in special needs? If so, then what Are they in a Special Education (i.e. Speech, resource, OT, PT,), 504, Gifted & Talented, Tutoring or other: Does your child have an IEP (Individualized Education Plan)? If so, Please bring a copy of his or latest one to first visit. Doctors/Diagnosis Your child s diagnosis: If no diagnosis, then what symptoms are you MOST concerned about? Doctors or other therapists that your child is currently seeing Assessments Completed Has your child had any assessment done? If so, by who and what were they? Are you interested in assessments for your child here at Inspire Behavior? We do not diagnosis, but do assessments to determine the course of treatment. Any Medication/Special Diets Medication that your child is currently taking: Any food allergies? Gluten/Casein free diet? Does your child have any reaction when they eat certain foods- don t eat for a period of time? Reinforcement/Motivation What are some are your child s favorite foods/toys/obsessions? Behavior/Emotional Regulation What are your top 2 concerns, if any?
6 When is this behavior/s mostly likely to occur? How have you or others so far addressed this? Social Skills What are your top 2 concerns, if any? Has your child lost any peers due to behavior? / Had emotional difficulties due to skills/anger issues/isolation/what is their play like? Have they had any intervention thus far? Academic/Developmental What are your top 2 concerns, if any? How have you or others so far addressed this? Environment (this is just to give a snapshot of environment in which the child lives: please understand there is no judging- just here for you..please be honest so we can help) Who does the child live with? (List all Family Members) What major life stressors (divorce, moves, loss of a job, a diagnosis) have you or your child experienced in the last 2 to 3 years. How is your daily life run? (i.e. does mom and dad work- child goes to YMCA afterschool) Is your child in any extra- curricular activities? *Give an example of a typical pick one: afternoon or morning in your home:
7 Fill out only if your child will be participating in ANY Equine Activity Inspire Behavior Therapy & Consulting Located at Open My World 1020 CR 270 Leander, TX RELEASE OF LIABILITY/EAL Inspire Behavior Therapy & Consulting or its officers, members, employees and agents will not be responsible for ANY damages to person, animal property at Open My World, its grounds, nor will they be responsible for any lost or destroyed. The undersigned rider/parent/guardian hereby releases Inspire Behavior Therapy & Consulting its officers, members employees and agents from any and all liability, claims and damages whatsoever (including costs, expenses and attorney fees) that might result from damages, injuries or losses to their person or property during, or in connection with, or arising out of any lesson, session, show, event or function, whether or not damages, injuries, or losses result directly or indirectly from the negligent act or omission of such released parties. Warning: Under Texas Law (Chapter 87, Civil Practice and Remedies Code), An Equine Professional Is Not Liable For An Injury To Or The Death Of a Participant In Equine Activities Resulting From The Inherent Risks Of Equine Activities. In exchange for the property use owned by Open My World and Inspire Behavior Therapy & Consulting and other value consideration, I agree that my use of the premises and any animals, facilities or equipment owned by Open My World and Inspire Behavior & Consulting is at my risk. I further agree to indemnify and hold harmless Open My World and Inspire Behavior Therapy & Consulting their respective officers, members, employees, and agents from any and suits, actions or claims of any type arising from my use of the premises or participation in the equine activity of such use by my guest whether or not such claims result directly or indirectly from the negligent act or missions of the indemnified parties or otherwise. I acknowledge that riding and involvement with horses is a high-risk activity. I have read this agreement and fully understand its content. X Name of Rider/EAP/EAL/Volunteer Signature of Volunteer or Parent/Guardian of minor
Program Director for Early Childhood Services Jennifer Haak Ph.D., BCBA D. Program Director for Adult Services Jeannie Aguilar Ph.D.
WELCOME! 1 of 13 Our Staff Founder & Executive Director Jennifer Kaut M.Ed., BCBA Co Owner & Managing Director Tarsah Dale M.Ed., BCBA Program Director for Early Childhood Services Jennifer Haak Ph.D.,
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