ABA INTAKE PACKET

Welcome to the University of Washington Autism Center!

Thank you for your interest in our clinical services at the University of Washington Autism Center! To help in the
first few steps of the intake process, here is a little bit of information about our ABA services and the intake
process.

Filling out the Registration Form provides us with all the information needed to get you on the waitlist(s) for
services. We have also attached additional intake forms specific to the service(s) you have expressed interest in.
These forms will provide the clinician with important information about the client and as such, we require that the
additional paperwork be turned in prior to scheduling. Below we have provided a list of our services and brief
descriptions of each to aid in deciding what services you may be interested in pursuing at our Center:

 Infant Clinic: A clinic for children 24 months and younger dedicated to early detection, monitoring, and
intervention when concerns about Autism Spectrum Disorder are present.
 Social Skills Group: Small group programs provide children with tools for navigating their social environment.
 Applied Behavior Analysis (ABA) Intervention Services: Our Behavior and Education Consultants (BEC)
provide evidence-based treatment based on the principles of applied behavioral analysis (ABA), in order to
identify individualized goals to support skill acquisition and address challenging behaviors, develop learning
activities and support individuals with autism in a variety of settings.
o Short Term Consultation: Can include problem focused parent coaching or school consultations.
o Parent Coaching: Consultants work with parents to implement ABA-based techniques in the home.
o Client-Focused Skills Coaching: Consultants work directly with the client on specific identified
skills
o Intensive In-Home ABA Program: Individualized home program supervision and training.
Thank you again for you interest in our services. Please don’t hesitate to contact the intake coordinator with any
questions or concerns. We look forward to working with you and your family!
Intake Coordinator
Office: (206) 616 – 8642 Fax: (206) 598 - 7815
Email: uwautism@u.washington.edu

Seattle Office Tacoma Satellite

Box 357920 Seattle, WA 98195-7920 Toll-free Information Line 1.877.408.UWAC Box 358455 Tacoma, WA 98402-8455
206.221.6806 fax 206.598.7815 uwautism@uw.edu 253.692.4721 fax 253.692.4718
http://depts.washington.edu/uwautism
 INTERPRETIVE SERVICES

_______________________________________________ (Name of Intake Personnel) have read or conveyed to the client/patient

designee the option to access interpretive service or seek reasonable accommodation in the completion of this
intake interview and document completion process.

At the time of this intake I have been given the opportunity to identify the need to access additional interpretive
service or reasonable accommodations to ensure the appropriate level of service delivery. Those services have
been identified below: ________ (client initials).

◯No additional services are needed at this time

◯Yes, I would like to discuss additional interpretive services or reasonable accommodations:

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

Parent/Guardian Signature: _______________________________________________ Date: _________________________________

Printed Name: ______________________________________________________________________________________________________________

Seattle Office Tacoma Satellite

Box 357920 Seattle, WA 98195-7920 Toll-free Information Line 1.877.408.UWAC Box 358455 Tacoma, WA 98402-8455
206.221.6806 fax 206.598.7815 uwautism@uw.edu 253.692.4721 fax 253.692.4718
http://depts.washington.edu/uwautism
 ABA INTAKE FORM

Seattle Office Tacoma Satellite

Box 357920 Seattle, WA 98195-7920 Toll-free Information Line 1.877.408.UWAC Box 358455 Tacoma, WA 98402-8455
206.221.6806 fax 206.598.7815 uwautism@uw.edu 253.692.4721 fax 253.692.4718
http://depts.washington.edu/uwautism
ABA Clinical Services Intervention Intake Form

Person Completing this Form

Name: ____________________________ Please indicate relationship to the client: ☐Parent ☐ Guardian ☐ Other:_____________

Are you authorized to consent for this individual’s healthcare? _____ No _____ Yes

Client Information

Client Name: ____________________________________________, ________________________________________________

Date of Birth: _______ / _______ / _________

Address: __________________________________________________________________________________

Please answer the following questions about the child’s living situation:

A. Are the child’s parents Divorced/Separated? _____ No _____ Yes

1) If Divorced/Separated:
Who is responsible for making medical decisions for the child? _____ Joint _____ Sole
If sole custody, please specify which parent: ____________________
With whom does the child reside? _____________________

B. Household 1: ______% time

Name of Parent or Guardian #1: ___________________________
Name of Parent or Guardian #2: ___________________________
Names, ages, and relation to child of all other individuals in the home:
____________________________________________________________________________________
____________________________________________________________________________________

C. Household 2: ______ % time

Name of Parent or Guardian #1: ___________________________
Name of Parent or Guardian #2: ___________________________
Names, ages, and relation to child of all other individuals in the home:
____________________________________________________________________________________
____________________________________________________________________________________

D. Are both parents aware of services being sought at the Autism Center? _____ No _____ Yes
Does your child have a Guardian Ad Litem? _____ No _____ Yes
If Yes, please provide their name: ____________________

E. Names and ages of any other siblings:

____________________________________________________________________________________
____________________________________________________________________________________

F. Primary Language: □ English □ Other: specify ______________

Percent time child is exposed to non-English language(s): ______%

Seattle Office Tacoma Satellite

Box 357920 Seattle, WA 98195-7920 Toll-free Information Line 1.877.408.UWAC Box 358455 Tacoma, WA 98402-8455
206.221.6806 fax 206.598.7815 uwautism@uw.edu 253.692.4721 fax 253.692.4718
http://depts.washington.edu/uwautism
Previous Evaluations/Assessments
Please list any school testing and/ or other evaluations of the client’s skills.

1. Has the client ever been assessed/evaluated by an Occupational Therapist, Speech and Language Therapist,
Psychiatrist, Psychologist, Special Educator, or other mental health counselor? ____ No ____ Yes ___
Unknown

If yes, please provide the following information:

A. Name: _________________________ Type of Specialist____________________ Date of evaluation: ______________
Purpose of Evaluation / Services: ___________________________________________________________
Results of Evaluation: ___________________________________________________________________________________________
___________________________________________________________________________________________

B. Name: _________________________ Type of Specialist____________________ Date of evaluation: ______________

Purpose of Evaluation / Services: ___________________________________________________________
Results of Evaluation: ___________________________________________________________________________________________
___________________________________________________________________________________________

C. Name: _________________________ Type of Specialist____________________ Date of evaluation: ______________

Purpose of Evaluation / Services: ___________________________________________________________
Results of Evaluation: ___________________________________________________________________________________________
___________________________________________________________________________________________

Educational History
Please list the schools attended from most recent.

1. Is the client currently enrolled in school or Birth-3 Services? ___ No ___ Yes ___ N/A
School Name: ________________________________ School District: _____________________________
Program or Grade level: ______________________________________________________________________

2. Please list any other schools that the client has attended:
A. School Name: ________________________________ School District: ___________________________
Years of attendance: ____________________________ Grade Levels: ________________________

B. School Name: ________________________________ School District: ___________________________

Years of attendance: ____________________________ Grade Levels: _________________________

C. School Name: ________________________________ School District: ___________________________

Years of attendance: ____________________________ Grade Levels: _________________________

3. Is the client receiving or has the client received special services or accommodations at school? ____ No ____ Yes

If yes, please explain what type: (e.g. IEP, IFSP, 504 Plan) ________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Seattle Office Tacoma Satellite

Box 357920 Seattle, WA 98195-7920 Toll-free Information Line 1.877.408.UWAC Box 358455 Tacoma, WA 98402-8455
206.221.6806 fax 206.598.7815 uwautism@uw.edu 253.692.4721 fax 253.692.4718
http://depts.washington.edu/uwautism
Client’s Interests
Please indicate anything that the clinicians should know when working with him/her.

1. Preferences (favorite activities, food, interests/topics, sensory):

________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________

2. Dislikes (aversions):
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________

3. Other:
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________

Concerns

1. Reason for seeking ABA Services [Please explain]:

________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
2. Please list client strengths:
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________

3. Developmental Concerns [Please indicate by marking the box and explaining each domain]

☐Cognitive/Learning ☐Motor

Seattle Office Tacoma Satellite

Box 357920 Seattle, WA 98195-7920 Toll-free Information Line 1.877.408.UWAC Box 358455 Tacoma, WA 98402-8455
206.221.6806 fax 206.598.7815 uwautism@uw.edu 253.692.4721 fax 253.692.4718
http://depts.washington.edu/uwautism
☐Behavior ☐Language

☐Social ☐Peer Interaction

☐Play/Leisure ☐Self-Help (Dressing/Toileting/Feeding/Etc.)

☐Dietary/ Allergies ☐Other

☐Academics (Reading/Writing/Math) ☐Executive Functioning

(Organization/Flexibility/Attention)

Seattle Office Tacoma Satellite

Box 357920 Seattle, WA 98195-7920 Toll-free Information Line 1.877.408.UWAC Box 358455 Tacoma, WA 98402-8455
206.221.6806 fax 206.598.7815 uwautism@uw.edu 253.692.4721 fax 253.692.4718
http://depts.washington.edu/uwautism
Description of Services

Applied Behavior Analysis (ABA) Intervention Services: Behavior and Education Consultants (BCBAs) provide
evidence-based treatment using Applied Behavior Analysis (ABA) strategies to teach new skills, develop
meaningful learning tasks, address challenging behavior, and support individuals with autism in a variety of
settings.

 Client-Focused Skills Coaching: BCBAs work directly with the client to build specific skills. This type of
therapy is only appropriate when recommended by your BCBA and may not be the best fit for all clients.

 Intensive In-Home ABA Program: The BCBA works with families to develop, implement, and refine an in-
home, intensive, comprehensive ABA-based programs individualized for each child. Home-based programs
are implemented by behavior technicians and supervised by the BCBA.

Hours of Availability
Please mark the times you and the client ARE available for services.

Monday Tuesday Wednesday Thursday Friday

8:00 am

9:00 am

10:00 am

11:00 am

12:00 pm

1:00 pm

2:00 pm

3:00 pm

4:00 pm

5:00 pm

6:00 pm

Additional Comments

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Seattle Office Tacoma Satellite

Box 357920 Seattle, WA 98195-7920 Toll-free Information Line 1.877.408.UWAC Box 358455 Tacoma, WA 98402-8455
206.221.6806 fax 206.598.7815 uwautism@uw.edu 253.692.4721 fax 253.692.4718
http://depts.washington.edu/uwautism
Cultural Considerations

Please describe below important cultural practices, rituals, traditions or beliefs that you believe are
important for us to be aware of prior to initiating a therapeutic relationship.

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Evaluations/Assessment Reports

Please attach a copy of your insurance card (front and back)

☐Check that a copy of each side is included with this packet

Please attach a copy of your child’s reports (please include all that apply):
☐Diagnostic Evaluation Report

☐IEP/IFSP/504 Plan

☐Functional Behavior Assessment (FBA) /Behavior Intervention Plan (BIP)

☐Prescription for ABA

☐Mental health directives

☐Medical advance directives

☐Powers of attorney

☐Discharge summaries or evaluations from any and all inpatient/outpatient services within the last 5 years

☐Least restrictive alternative orders

☐Other: ____________________________________

Coordination of Care

Please list and provide contact info for all other providers for your child:

☐Primary care provider: ______________________________________ Contact: ________________________

☐School teacher: ______________________________________ Contact: ________________________

☐Speech Language Pathologist: _______________________________ Contact: ________________________

Seattle Office Tacoma Satellite

Box 357920 Seattle, WA 98195-7920 Toll-free Information Line 1.877.408.UWAC Box 358455 Tacoma, WA 98402-8455
206.221.6806 fax 206.598.7815 uwautism@uw.edu 253.692.4721 fax 253.692.4718
http://depts.washington.edu/uwautism
 ☐Occupational Therapist: ____________________________________ Contact: ________________________

☐Other: ______________________________________ Contact: ________________________

☐Other: ______________________________________ Contact: ________________________

☐Other: ______________________________________ Contact: ________________________

Please list any medications your child is taking, the purpose of the medication, dosage and any concerns:

Seattle Office Tacoma Satellite

Box 357920 Seattle, WA 98195-7920 Toll-free Information Line 1.877.408.UWAC Box 358455 Tacoma, WA 98402-8455
206.221.6806 fax 206.598.7815 uwautism@uw.edu 253.692.4721 fax 253.692.4718
http://depts.washington.edu/uwautism
 INSURANCE BILLING INFORMATION and AUTHORIZATION

◯ I am a private pay client and acknowledge it is my personal responsibility to pay for services.

o Board Certified Behavior Analyst hourly fee is $152 per hour for assessments, consultations,
supervision, meetings, and therapy.
o Applied Behavior Analysis Behavior Technician fee is $54 per hour.

◯ I authorize my insurance provider(s) listed below to make payments directly to UW Autism Center for services
rendered.

◯ I understand that a copy of my insurance card (front and back) will be retained in my client/patient file for billing
purposes.

◯ I agree that private information may be shared with my insurance carrier for billing purposes.

◯ I understand that if I do not want information shared that I may submit specific direction to UW Autism Center
(UW Autism Center) (See UW Autism Center Release Form).

Name of Primary Sponsor: ________________________________________________________SS# _______________________________________

Name of Insurance Carrier ________________________________________________________Policy # ___________________________________

Name of Secondary Sponsor: _____________________________________________________SS# ________________________________________

Name of Insurance Carrier ________________________________________________________Policy # ___________________________________

Medicare/Medicaid Identification# ___________________________________________________________________________________________

Seattle Office Tacoma Satellite

Box 357920 Seattle, WA 98195-7920 Toll-free Information Line 1.877.408.UWAC Box 358455 Tacoma, WA 98402-8455
206.221.6806 fax 206.598.7815 uwautism@uw.edu 253.692.4721 fax 253.692.4718
http://depts.washington.edu/uwautism
 PATIENT / CLIENT SUPPLEMENTAL INFORMATION
[WAC 388-877-0610- (2) g-i]

Has the client or any family member been court ordered to mental health or chemical dependency treatment?

◯ Yes ◯ No
If Yes, please provide details and a copy of the court documents:
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________

Is the client or any family member under department of corrections supervision?

◯ Yes ◯ No
If Yes, please provide details:
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________

Does the client and/or family member have a history of substance abuse, including tobacco?
◯ Yes ◯ No
If Yes, please provide details:
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________

Does the client and/or family member have a history of pathological gambling?
◯ Yes ◯ No
If Yes, please provide details:
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________

Has the client been identified to be at risk of harm to self and/or others, including suicide and/or homicide?
◯ Yes ◯ No
If Yes, please provide details:
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________

Does the client have any history of trauma or abuse?

◯ Yes ◯ No
If Yes, please provide details:
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________

Seattle Office Tacoma Satellite

Box 357920 Seattle, WA 98195-7920 Toll-free Information Line 1.877.408.UWAC Box 358455 Tacoma, WA 98402-8455
206.221.6806 fax 206.598.7815 uwautism@uw.edu 253.692.4721 fax 253.692.4718
http://depts.washington.edu/uwautism
Parent / Family Preferences
Please list the top three areas/goals you would like to see improvement for the client in next 6 months:

1.

2.

3.

Seattle Office Tacoma Satellite

Box 357920 Seattle, WA 98195-7920 Toll-free Information Line 1.877.408.UWAC Box 358455 Tacoma, WA 98402-8455
206.221.6806 fax 206.598.7815 uwautism@uw.edu 253.692.4721 fax 253.692.4718
http://depts.washington.edu/uwautism
 INFORMATION DISCLOSURE TO CLIENTS
WAC 388-877-0640 (1) under RCW 18.19.060

Purpose and Approach to Treatment:

Thank you for choosing UW Autism Center as your ABA Therapy Provider. At UW Autism Center our mission is to
promote progress for every client; progress that is based in science and enhanced by the personal touch of our staff
members. We strive to become Washington’s leading Autism Treatment Agency by delivering our model of client-
centered, individualized, wraparound therapeutic services. We create individualized programs for all our clients
based on a thorough functional assessment of their strengths and weaknesses. We develop fun and exciting
learning environments so that every patient/client can reach their full potential.

Individual Providers
UW Autism Center provides Board Certified Behavior Analysts (BCBA) to serve as Program Supervisors. BCBA’s
are responsible for conducting detailed data-based assessments, overseeing the quality and direction of the clients’
therapy programs, consulting with family members and other caregivers in order to provide guidance and ensure
progress, analyzing daily data collection and decision-making based on the data collected during all therapy
sessions. UW Autism Center ensures that all Board Certified Behavior Analysts are current with their certification
and maintain their continuing education requirements to maintain certification with the Behavior Analyst
Certification Board [BACB].

Also provided are behaviorally-trained ABA Therapists to conduct ABA therapy sessions and sessions in other
areas on a regular basis. Behavior Technicians must have completed a minimum of 12 semester hours (or
equivalent) of college coursework and currently be enrolled in course of study leading to an associate's or
bachelor's degree (psychology, education, social work, behavioral sciences, human development or related
fields) Have completed a minimum of 48 semester hours (or equivalent) of college coursework. Upon hire, an
additional 40 hours of classroom training and supervised fieldwork is required. Copies of licenses, trainings and
certifications are stored in each employee’s file. Most of our Behavior Technicians hold a degree in the Behavioral
Sciences, Psychology or a related field such as; Education, Human Development, or Social Work/Behavioral Health.

UW Autism Center is licensed by the Department of Social and Health Services, Division of Behavioral Health
Resources as a Licensed Behavioral Health Agency, and is also certified by the Department of Social and Health
Services, Division of Behavioral Health Resources to deliver ABA services. Each BCBA and Behavior Technician are
granted a Behavioral Health Agency Affiliated Registration by the Washington Department of Health. A BCBA or
Behavior Technician are NOT qualified to diagnose a mental/behavioral health condition.

Client Rights (WAC 388-877-0600; WAC 388-877-0680) See attached Client Rights.
As a patient/client receiving services in the State of Washington, you have the right to: 1) Choose the provider and
treatment approach that best suits your needs and purposes; 2) have full and complete knowledge of your
provider’s qualifications and training; 3) be fully informed as to the terms under which services will be provided;
and 4) refuse treatment.
You may file a complaint with the UW Autism Center or with the Division of Behavioral Health and Recovery
(DBHR) by sending a letter, calling, or emailing. We will not retaliate against you for filing a complaint.

UW Autism Center Compliance Officer; Box 357920; Seattle, WA 98195-7920

206-221-6806, Toll-Free: 877-408-8922; Email: uwautism@uw.edu

Seattle Office Tacoma Satellite

Box 357920 Seattle, WA 98195-7920 Toll-free Information Line 1.877.408.UWAC Box 358455 Tacoma, WA 98402-8455
206.221.6806 fax 206.598.7815 uwautism@uw.edu 253.692.4721 fax 253.692.4718
http://depts.washington.edu/uwautism
 Division of Behavioral Health and Recovery;
Complaint Manager: 360-725-3752
Email: DBHRcomplaintmgr@dshs.wa.gov

Department of Health
Health Systems Quality Assurance (HSQA)
Complaint Intake
P.O. Box 47857
Olympia, WA 98504-7857
360-236-4700
Email: HSQAComplaintIntake@doh.wa.gov

Reporting and Documentation of Suspected Abuse, Neglect, & Exploitation [WAC 388-877-0420 (11)]

Employees of UW Autism Center are notified upon their employment that they are required by law (RCW: Chapters
26.44 and 73.34) to report suspected abuse to their manager and/or appropriate state or local authorities. All
clinical records will contain proper documentation pertaining to suspected abuse. Please refer to Job Description
Documents for details on how to report abuse. All cases will be reported/debriefed to the Director of ABA Services,
and documented in the patient/client file.

Referral Resources
Assessments and referrals for ABA therapy can be obtained by an appropriate provider type
including: psychiatrist, developmental pediatricians, pediatric neurologists, and psychologists trained in the
diagnosis of Autism Spectrum Disorders. The Washington State Health Care Authority has a comprehensive list of
Centers of Excellence for Autism at:
http://www.hca.wa.gov/medicaid/abatherapy/Documents/HCA_Centers_of_Excellence_for_ASD.pdf

The Washington State Licensing Department asks that you be informed of the following: “Licensed providers
practicing for a fee must be credentialed with the Department of Health for the protection of the public health and
safety. Credentialing of an individual with the department does not include recognition of any practice standards,
nor necessarily implies the effectiveness of any treatment.”

Seattle Office Tacoma Satellite

Box 357920 Seattle, WA 98195-7920 Toll-free Information Line 1.877.408.UWAC Box 358455 Tacoma, WA 98402-8455
206.221.6806 fax 206.598.7815 uwautism@uw.edu 253.692.4721 fax 253.692.4718
http://depts.washington.edu/uwautism
 Client Communication Agreement

The UW Autism Center would like to know your preferences by which we may contact you regarding your services.

I do not have a preference, UW Autism Center may contact me using either email or phone No Yes

I prefer the majority of all contact to take place via phone No Yes
If yes, please indicate below best contact number(s):

Home Number:______________________________ Best time(s) to call: __________________

Is it ok to leave a message at this number? No Yes

Work Number: ______________________________ Best time(s) to call: ___________________

Is it ok to leave a message at this number? No Yes

Cell Number: ______________________________ Best time(s) to call: ___________________

Is it ok to leave a message at this number? No Yes

I prefer the majority of all contact to take place via email No Yes
If yes, please review and sign the consent for email below:

Individual Providers and clients may decide to use email to facilitate communication. Some Providers at UW Autism Center may
communicate via email, but this agreement does not obligate all UW Autism Center Providers to communicate via email. Email
may be one of many forms of communication with UW Autism Center.

Risk of using email

I want to use email to communicate to UW Autism Center Providers and staff about my/the client’s personal health care. I
understand that UW Autism Center Providers and staff will use reasonable means to protect the security and confidentiality of
email information sent and received. I understand that there are known and unknown risks that may affect the privacy of my
personal health care information when using email to communicate. I acknowledge that those risks include, but are not limited,
to:
 Email can be forwarded, printed, and stored in numerous paper and electronic forms and be received by many
intended and unintended recipients without my knowledge or agreement.
 Email may be sent to the wrong address by any sender or receiver.
 Email is easier to forge than handwritten or signed papers.
 Copies of email may exist even after the sender or the receiver has deleted his or her copy.
 Email service providers have a right to archive and inspect emails sent through their systems.
 Email can be intercepted, altered, forwarded, or used without detection or authorization.
 Email can spread computer viruses.
 Email delivery is not guaranteed.

Conditions for the use of email

I agree that I must not use email for medical emergencies or to send time sensitive information to my/the client’s Providers. I
understand and agree that it is my responsibility to follow up with UW Autism Center Providers or staff, if I have not received a
response to my email within a reasonable time period.

I agree that the content of my email messages should state my question or concern briefly and clearly and include (1) the subject
of the message in the subject line, and (2) clear identification including client’s name, parent’s name, and telephone number in
the body of the message. I agree it is my responsibility to inform UW Autism Center of any changes to my email address. I agree
that, if I want to withdraw my consent to use email communications about my/the client’s healthcare, it is my responsibility to
inform my/the client’s Providers or staff member only by email or written communication

Understanding the use of email

I give permission to UW Autism Center Providers and staff to send me email messages that include my/the client’s personal
health care information and understand that my email messages may be included in my/the patient’s medical record. I have
read and understand the risks of using email as stated above and agree that email messages may include protected health
information about me/the client, whenever necessary.
Email address: ________________________________________________________________________________________________________________________________

Print client’s name____________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________
Signature (Parent/Guardian if under 18) Date

___________________________________________________________________________________________________________________________________________________
Printed Name Relationship to client

___________________________________________________________________________________________________________________________________________________
Signature of Client (if client is 13yrs or older) Date
 SIGNATURE and ACKNOWLEDGEMENT

Parent/Guardian Signature: ______________________________________________________ Date: _____________________________________

I hereby certify that the above statements are true and correct to the best of my knowledge and understand all information in this packet will
become part of the patient’s clinical file.

Parent/Guardian Name:
________________________________________________________________________________________________________

BCBA/Supervisor Signature: _____________________________________________________ Date: _____________________________________

by signing, I hereby confirm that I have reviewed with the parent/guardian the information set forth in this document and understand all
information in this packet will become part of the patient’s clinical file.

BCBA/Supervisor Name: ______________________________________________________________________________________________________

BCBA Certificate #_______________________________ DOH Counselor Agency Affiliate License #_______________________________

Seattle Office Tacoma Satellite

Box 357920 Seattle, WA 98195-7920 Toll-free Information Line 1.877.408.UWAC Box 358455 Tacoma, WA 98402-8455
206.221.6806 fax 206.598.7815 uwautism@uw.edu 253.692.4721 fax 253.692.4718
http://depts.washington.edu/uwautism