PROVISIONAL BEHAVIORAL SERVICES AGREEMENT

This service agreement (“Agreement”) sets forth the terms and conditions upon which Applied Behavior Health Services (“we” or “us”) offers behavioral services to you for private pay. You are referred to in this agreement as “Client” or “you.” Please review this Agreement carefully and contact me with any questions. If you agree to proceed as the newest client of Applied Behavioral Health Services, please sign and date this Agreement on the final page.

SCOPE OF SERVICES UNDER THIS AGREEMENT

Most of our services are behavioral in nature and covered under our certification from the Behavior Analyst Certification Board® (BACB). Services designated on our website as nonbehavioral services (marked with an asterisk*) are not covered under our certification from the BACB®. We are not mental health therapists, and we do not offer therapeutic services such as talk therapy or psychotherapy.

We agree to provide you with behavioral services based on the principles of applied behavior analysis (or ABA) aligned with the BACB®’s Ethics Code for Behavior Analysts. You’re encouraged to review this document online and hold us accountable to ethical behavior analytic practices. You may also request a hard copy from us. This document further details our obligations of confidentiality.

YOUR RESPONSIBILITIES

We ask you to provide accurate and relevant information that will help us best serve you and/or your child(ren).

We ask you to attend all scheduled appointments and to let us know 48 hours in advance if you need to cancel or reschedule. Appointments will be considered missed if you are 15 minutes or more late and did not provide notice. Missed appointments will be billed at the same rate as the scheduled appointment. Appointments cancelled between 48 hours before the appointment up to one hour before the time of the appointment will be billed at $25. Appointments cancelled one hour prior to the appointment will be billed at $40.

We ask you to follow all treatment protocols outlined in consultation sessions and/or treatment plans and arrive at all sessions prepared, groomed, and appropriately dressed. When working with your child in person, we ask you to assume all liability for the health and safety of your child. If we work with your child in the home, we ask that you are present and engaged during all sessions and provide a public space within the home. We will not work with your child behind closed doors or in spaces of the home that cannot be observed by you.

OUR RESPONSIBILITIES

We will abide by the Ethics Code for Behavior Analysts as set forth by the BACB® and previously mentioned in this Agreement. This includes your rights to confidentiality. We will not communicate information about your or your child to any individual, except as may be required by law, unless you have signed a Release of Information. We will similarly arrive on time, prepared, groomed, and appropriately dressed.

FEES AND PAYMENT

Currently, we are not credentialed by any insurance providers and do not accept insurance payment. All payments will be initiated by your or by us and processed with our authorized third-party vendors on our website or by invoice. Web payments are initiated by you and processed with our third-party vendor SQUARESPACE Payments. Invoices are initiated by us and processed with either SQUARESPACE Payments or Found (Piermont Bank). We do not retain your payment information, which is subject to the privacy policies of the third-party vendors.

All payments are due in advance of the session or promptly at the end of a session. Appointments following a missed payment will be put on hold until payment is made.

The cost of this retainer to initiate services with us as a provisional client is covers payment for your intake assessment (up to 90 minutes) including a review of one relevant evaluation/assessment, development of treatment goals and procedures, and your first 60-minutes of consultation. Additional evaluations/assessment may be considered at a rate of $25 per document.

This Agreement neither obligates your nor us to continue with our client-provider relationship. This allows you the opportunity to ensure our treatment approach is the right fit for you and/or your child(ren). If you honor us with your choice to continue our client-provider relationship, a lengthier formal contract will follow. We will guide you through the process of selecting the best treatment package and cost for your needs, as described on our website.

TERM AND TERMINATION

This Agreement shall be effective as of dates of signature and shall remain in effect until services are delivered by us to you. If you decide to terminate provisional services prior to delivery of services by us to you, we will provide an 80% refund of the cost of this retainer. If you decide to terminate provisional services during or after we begin delivery of services to you, we are unable to provide a refund.

By making this purchase, you acknowledge you have read this Agreement in its entirety, agree to its terms and conditions, and that you are legally authorized and mentally competent to do so.