This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and new client rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that we obtain your signature acknowledging that we have provided you with this information. Although these documents are long and sometimes complex, it is very important that you read them carefully and that you ask questions you have about the procedures at any time.

When you sign this document, it will also represent an agreement between us. You may revoke this agreement in writing at any time. That revocation will be binding on us unless we have taken action in reliance on it; if there are obligations imposed on us by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred. If you have any questions or concerns, please feel free to discuss them with us.

We will provide services specifically designed to help you (and/or your minor child), or otherwise provide you with referrals to other professionals. Our clinical and behavioral services consist primarily of individual assessments (psychological and behavioral evaluations), training, in-home and in-school consultation and observations, long-term service provision to youth in the autism spectrum, and short-term consultations with individuals, guardians  , educators, and other related professionals.

It is important that individuals be able to perform at their best during sessions. Please let us know before you arrive (and as soon as possible) if the individual preparing for session is not feeling well, or is taking any prescribed or over-the-counter medications that we have not been told of in advance. In such cases, the session may need to be rescheduled. Individuals participating in appointments and sessions should be well rested and should bring snacks for breaks during the session. Because of the variety of dietary restrictions we do not offer any food or snacks in our clinic. guardians should plan to remain in the office during sessions with their minor children unless other (previous) arrangements have been specifically discussed with us and agreed to by us.

Psychological services are best provided in an atmosphere of trust. Because trust is so important, all services are confidential except to the extent that you provide us with written authorization to release specified information to specific individuals, or under other conditions and as mandated by California and Federal law and our professional codes of conduct/ethics. These exceptions are discussed below.

If we have reason to suspect that a minor, elderly, or disabled person is being abused, we are required to report this (and any additional information upon request) to the appropriate state agency. If we believe that a client is threatening serious harm to him/herself or others, we are required to take protective actions which could include notifying the police, an intended victim, a minor’s guardians, or others who could provide protection, or seeking appropriate hospitalization.

Psychologists and Behavior Analysts routinely consult about cases with other professionals. In doing so, we make every effort to avoid revealing the identity of our clients, and any consulting professionals are also required to refrain from disclosing any information we reveal to them. Unless you object, we do not typically tell clients about these consultations; however, these consultations will be so noted in your Private Health Information. If you want us to talk with or release specific information to other professionals with whom you are working, you will first need to sign an Authorization that specifies what information can be released and with whom it can be shared.

We will review all testing results during our feedback session, and offer you opportunities to review raw testing data with us. You will receive a written report that summarizes our findings. This report will include a summary and interpretation of all individual testing, as well as impressions from individual observations and consultations conducted as a part of a comprehensive individual evaluation. Upon your request, we are happy to provide you with a written summary of our impressions from other meetings, consultations, or observations as well. We will forward copies of any reports or written summaries to others only with specific, written consent from you. Because of the proprietary nature of testing materials, we will release raw testing data only to other appropriately credentialed professionals (except as otherwise required by law).

If you are involved in a court proceeding and a request is made for information concerning our professional services, such information is protected by the provider -patient privilege law for Active Steps but there is limited protection for information conveyed to others employed by or consulting to Active Steps, LLC under the law.

Active Steps cannot provide any information without your written authorization, open DCFS investigation, National Security investigation, or a court order.

However, we may be forced to reveal information. In that case, we will reveal only the minimally acceptable amount of information. If you are involved in, or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information. Also, if a client files a complaint or lawsuit against anyone affiliated with Active Steps, LLC, we may disclose any and all relevant information regarding that client we deem necessary in order to defend ourselves.

PAYMENT FOR SERVICES (where applicable)

Members are responsible for fees associated with services thatIf you have a question or objection to fees assessed objections or inquiries must be made within 90 days of receipt of the relevant invoice in order to allow review and consideration. Inquiries regarding invoices over 90 days old will be deemed untimely and payment will be expected for services. If necessary, we may seek assistance from an outside party in order to collect payment for services. In such cases, any disclosures are limited to the minimum that is necessary to achieve the purpose. As you might suspect, the laws and professional standards governing these issues are quite complex, and it is important that we discuss any questions or concerns that you (or your minor child) may have at our first meeting, and as they may arise in the course of our work together. If any of these types of situations arise, we will make every effort to fully discuss it with you before taking any action, and we will limit my disclosure to what is necessary. We are not attorneys, however, and you may wish to obtain formal legal consultation if you need specific advice.

If a client is under eighteen (18) years of age, the law may provide guardians with the right to examine the minor child’s records. Privacy, however, is often crucial to successful progress in treatment and valid evaluation results. If, in the course of an evaluation or consultation, a minor child reveals to us information that he or she does not want shared with his or her guardians or guardian, we usually do not reveal such information unless we believe that there is a high risk that the minor will seriously harm him/herself or others, and in which case we will notify him or her of my intent to notify his/her guardians or legal guardian(s).

Clients should be aware that, pursuant to HIPAA, we keep clients’ Protected Health Information in two sets of professional records. One set constitutes the Clinical Record. It includes information about reasons for seeking our professional services; the impact of any current or ongoing problems or concerns; assessment, consultative, or therapeutic goals; progress towards those goals, a medical, developmental, educational, and social history; treatment history; any treatment records that we receive from other providers; reports of any professional consultations; billing records; releases; and any reports that have been sent to anyone, including statements for your insurance carrier. Except in unusual circumstances that involve danger to themselves or others, or makes reference to another person (unless such other person is a health care provider) and we believe that access is reasonably likely to cause substantial harm to such other person, they or their legal representative may examine and/or receive a copy of your Clinical Record, if they request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers, or may contain information that is protected by federal copyright laws. For this reason, we recommend that they initially review, or have them forwarded to another mental health professional so that they can discuss the contents. In most situations, we are allowed to charge a fee for copying (and for certain other expenses) plus postage and this is regulated under California Law. The exceptions to this policy are contained in the attached Notice Form. If we refuse the request for access to their records, they have a right of review (except for information provided to us confidentially by others) which we will discuss upon request. In addition, we also keep a set of Personal Notes for most clients to whom we provide even brief or consultative services. These notes are for our own use and are designed to assist us in providing clients with the best treatment. While the contents of Personal Notes vary from client to client, they include references to conversations, psychological testing, recording forms, our analysis of those conversations, and the effects of these conversations on our clients. They also may contain particularly sensitive information revealed to us that is not required to be included in the Clinical Record (and information supplied to us confidentially by others). These Personal Notes are kept separate from the Clinical Record. Personal Notes are not available to clients and cannot be sent to anyone else, including insurance companies. The client's signature waives all rights, now and in the future, to accessing these records. Insurance companies cannot require authorization as a condition of coverage nor penalize one in any way for their refusal to provide it.

HIPAA provides clients with several new or expanded rights with regard to their Clinical Record and disclosures of protected health information. These rights include requesting that we amend a record; requesting restrictions on what information from ones Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that one has neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints the client make about our policies and procedures recorded in their records; and the right to a paper copy of this Agreement, the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with our clients.

Active Steps LLC has a culturally and ethnically diverse population of both staff and families served. It is never acceptable under ANY circumstances that a person or persons engage in discriminatory and bigoted behavior, and this will not be tolerated no matter who the perpetrator.

At Active Steps LLC we strongly believe, and follow a ZERO TOLERANCE policy and have implemented a Discriminatory Protocol should any staff member, client and/or intern be subjected to ANY discriminatory behavior or bigotry in the workplace, via in-person or Telehealth session. Our commitment applies to all persons involved in the operation of Active Steps, LLC and prohibits unlawful treatment and/or discrimination of any form.

Given our many professional commitments, we are often not immediately available by telephone. If you need to leave us a message, we will make every effort to return your call promptly (within 24-48 hours with the exception of holidays and weekends).

If you are difficult to reach, please leave some times when you will be available. Because of the nature of the services we usually provide, we do not provide on- call coverage 24 hours per day, 7 days per week. In emergency or crisis situations, please contact your physician, or call 911 and/or go to the nearest hospital emergency room.

Your signature(s) below indicates that you have read the information in this document and agree to be bound by its terms, and that you have received the HIPAA notice form described above or have been offered a copy and declined. Consent by all guardians  /legal guardians (those with legal custody) is required.

This document  serves as an agreement outlining the financial responsibilities associated with the members Insurance coverage. Please review the terms and conditions below, and feel free to contact our billing department if you have any questions.

Our Accounting  department can be reached at Accounting@active-steps.com for any inquiries or to discuss your account.

I, ___ ___, the legal guardian or guardian of ___ ___, hereby provide my consent for ___ ___ to act as the responsible guardian for my child during Applied Behavior Analysis (ABA) therapy sessions.

In the event of an emergency or if I cannot be reached, the responsible guardian, Responsible Guardian, is authorized to make decisions concerning my child's safety, including seeking medical care or contacting emergency services.