Potter Road Center

Behavioral Treatment Program

Parent Handbook
2019
Effective 02/1/2019
Revised 08/27/2019
Table of Contents
Introduction
● Welcome letter and manual purpose…………………………………………………………………...……………………………….2
● About ABA of Wisconsin Services
○ Mission Statement……………….………………………………………………………………………………….………………..3
○ Services Available……………………………………………………………………………………………………………………..3
○ Staff Information………………………………………………………………………………………………………………………..4
○ Contact Information……………………………………………………………………………………………..…………………...4

Starting Services
● Enrollment……………………………………………………………………………………………………………………………...………………..5
● Funding…………………………………………………………………………………………………………………………………..………………..5
● Assessment …………………………………………………………………………………………………………………………....................5
Ongoing Services

● Scheduling and Hours of Operation

○ Scheduling…………………………………………………………………………………………………..…………………………….6
○ Hours of Operation…………………………………………………………………………………………...……………………...6
● Arrival and Departure Policy and Procedures…………………………………………………..………………………………...7
● Attendance Policy……………………………………………………………………………………....………………………………………….7
○ Sickness Policy……………………………………………..……………………………………………………………………...8-9
○ Inclement Weather Policy………………………………………………………...……………………………………...….8-9
○ Attendance……………………………………………………………………………….………………………...……………….9-10
● Visitor Acknowledgement & Policy……………………………………….………………………………………...………….........10
○ Visitors in Instructional Areas…………………………………………………………….………………………………….10
● Snacks and Meal Times………………………………………………………………………………………………………….…………...11
● Toileting and Additional Clothing………………………………………………………………………………………………………….11
● Napping Policy……………………………………………………………………………………………………………………………………...12
● Medication Administration Policy…………………………………………………………………………………………………..12-14
● Injury, Illness, and Incident Reporting Procedures
○ Injury and Illness reporting and procedures………………………..………………..………………….………...14
○ Basic First Aid, Contacting Physicians, Emergency Situations………….……………………………..15
○ Incident Reporting……………………………………………………………………………………………………………….…15
● Caregiver Participation
○ Caregiver Training………………………………………………………….……………………………………………………….16
○ Generalization Sessions……………………………………………………………….…………………………………...….16
● Restraint and Seclusion Policy and Procedures………………………………………………………………………....16-17

Agreements

● Client Bill of Rights and Responsibilities……………………………………….……………………………….………..….17-19

● Notice of Privacy Practices…………………………………………………………………………………………………………...20-24
● Photography Consent……………………………………………………………………………………………………….…………........24
● Service Agreement…………………………………………………………………………………………………………...…………..24-26

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Dear families and caregivers,

We are thrilled to be working with you and your participant and appreciate the trust that
you have in ABA of Wisconsin to provide high-quality behavior analytic services. We
look forward to the opportunity to promote positive behavior change through teaching
your participant the skills needed to increase independence and improve interactions
with those around them.

The purpose of the following handbook is to provide an easy to reference resource

regarding services provided at the ABA of Wisconsin Potter Road Center. We hope that
you will use this handbook as a reference throughout the duration of receiving services
through ABA of Wisconsin.

We ask that you initial, sign, and return the final page of the parent handbook to ensure
that you have read and agree to follow the policies described in this handbook.

If there are any questions regarding the information provided in this handbook or any
questions regarding services provided at our Potter Road Center, please contact Nicole
Scharrer, Treatment Center Supervisor, at [email protected], or
262-200-0900, Ext. 2104 or Amelia McGoldrick, Director of Clinical Services, at
[email protected], or 262-200-0900, Ext. 2105.

Thank you,

ABA of Wisconsin Behavioral Treatment Team

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About ABA of Wisconsin Services

Mission Statement

We are committed to providing the highest quality, research-driven behavioral services to assist
individuals in achieving their full potential.

Services Available

ABA of Wisconsin, LLC uses principles of applied behavior analysis (ABA) to develop
research-based strategies to address challenging behaviors or learning deficits and enhance
our participants lives by:

● Conducting state-of the-art assessments that identify the specific functions of

challenging behaviors.
● Designing customized programs based on individual needs to immediately impact and
encourage positive behaviors.
● Providing in-service and ongoing training for parents and professionals to coordinate
programs and maximize the generalization of learned skills and new behaviors.
● Designing and implementing data collection systems and continuously monitoring
participant progress to make changes as needed to ensure participant progress.
● Writing reports and progress summaries of each individual's program and recommended
program modifications, if necessary.

An assessment is conducted to determine the service delivery model that is most appropriate to
meet your participant’s needs. Please let your assigned BCBA know if you have any questions
or concerns regarding the service delivery model that is being provided for your participant.
Definitions:
● Comprehensive ABA treatment: Treatment addresses a wide range of skill deficits
across multiple affected developmental domains, such as cognitive, communication,
social, emotional, and adaptive functioning. Maladaptive behaviors, such as
noncompliance, tantrums, and stereotypy are also typically addressed through
treatment. Comprehensive ABA treatment is typically provided for a higher number of
hours each week (approximately 30-40 hours per week).

● Focused ABA treatment: Treatment addresses a narrow range of skill deficits and
behavioral targets (e.g., challenging behavior, coping skills, and communication) and are
provided for a lower number of hours each week (up to 20 hours per week). Treatment
addresses a limited number of key functional skills and acute problem behavior, ensure
that the participant’s caregivers are able to maintain progress through caregiver training,
then ABA supports are faded out.

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Staff Informa on

Our team is comprised of Wisconsin-licensed and Board Certified Behavior Analysts (BCBA and
BCBA-D), Behavior Treatment Therapists (BTTs) and Behavior Technicians (BTs).

ABA of Wisconsin serves individuals from birth through adulthood. Staff have experience with a
range of diagnoses.

Definitions:
● Board Certified Behavior Analyst (BCBA): All of our BCBAs are licensed in the state of
Wisconsin, have a master’s degree in applied behavior analysis or a related field, have
completed a practicum providing applied behavior analysis services, and have a national
certificate through the Behavior Analysis Certification Board. BCBAs complete
participant assessments, develop treatment plans, and provide ongoing supervision to
Behavior Treatment Therapist and Behavior Technician staff.

● Behavior Treatment Therapist (BTT): BTTs have previous experience providing services
as a behavior technician and provide direct treatment and ongoing supervision to
Behavior Technicians. BTTs conduct procedural integrity checks to ensure high
treatment integrity and develop programming for treatment objectives under the
supervision of a BCBA.

● Behavior Technician (BT): BTs provide direct treatment consisting of skill acquisition and
behavior reduction programs under the supervision of a BTT and BCBA.

Contact Informa on

● ABA of Wisconsin Potter Road Center

o 10930 West Potter Road, Suite A, Wauwatosa, Wisconsin 53226
o 262-200-0900
● Amelia McGoldrick, Director of Clinical Services
o [email protected]
o 262-200-0900, Ext. 2105
● Nicole Scharrer, Treatment Center Supervisor
o [email protected]
o 262-200-0900, Ext. 2104

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Star ng Services
Enrollment
ABA of Wisconsin provides our participant’s family with a packet of information that is required
to be completed prior to starting services with ABA of Wisconsin. All of the information
requested is required in order to secure a prior authorization for funding to start a participant’s
assessment and services. If assistance is required to complete the enrollment paperwork or any
additional paperwork that is required throughout the course of treatment, please contact
Heather Hildman at [email protected] or 331-481-6477.

Funding
ABA of Wisconsin works with a variety of funding sources. After your insurance verification form
is received, ABA of Wisconsin completes a benefits verification to determine if ABA services are
covered by your funder. Additional benefits verifications will be completed throughout the course
services to ensure that services will continue to be funded.
If there are any changes to insurance or medicaid plans at any point throughout services,
parents/guardians must provide updated insurance or medicaid information as soon as
possible. Blank insurance verification forms can be found at the end of this handbook or in the
waiting room.

Assessment

All ABA services start with an assessment to identify treatment objectives and develop your
participant’s treatment plan. Parents/guardians may be asked to assist in gathering some
information or data during the assessment process. If ABA services will focus on increasing a
participant’s skills, the assessment will evaluate the participant’s current level of performance on
these skills and determine which instructional strategies and interventions are most likely to
prove effective. If ABA services will focus on decreasing ongoing problem behaviors, a
functional assessment and/or functional analysis activities (e.g., interviews, checklists, direct
observations) will be conducted. These assessment tools are designed to provide information
critical to the development of effective treatment procedures. A combination of assessment
strategies may be used, depending on your participant’s needs.

After the assessment is complete, a treatment plan will be developed and submitted to funders
for approval. It may take up to 22 business days to receive authorization to provide services.
Before starting services, the treatment plan will be reviewed with parents/guardians and
parents/guardians will be asked to provide a signature indicating that they consent to treatment
described in the treatment plan.

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Scheduling and Hours of Opera on
Scheduling
Your participant’s schedule is based upon their specific needs and availability for ABA services.
Our scheduling team will work to accommodate your and your participant’s existing schedule as
much as possible; however, we ask that you provide availability that will allow our team to
provide the recommended number of treatment hours. It is our policy to provide treatment at the
recommended dosage for all participants. If your participant’s personal schedule prevents them
from being available for the prescribed treatment hours, services may be suspended until they
are available. If your participant’s schedule will be changing, we ask that you provide an
updated availability form as soon as possible, with a minimum 30 days of the change in
availability whenever possible. Blank availability forms can be found at the end of this handbook
or in the waiting room.
If an emergency results in the inability to provide services at ABA of Wisconsin’s Potter Road
Center, arrangements will be made to provide services at the participant’s home or another
designated location. The schedule for ABA services in home may be altered from in-center
schedules to account for staff travel time to and from client’s homes.

Hours of Opera on
ABA of Wisconsin’s Potter Road Center’s Hours of operation are as follows:
● Regular Hours (September-May):
○ Monday-Thursday 8:00 am - 7:00 pm
○ Friday: 8:00 am - 5:30 pm
○ Saturday: 8:00 am - 3:00 pm

● Summer Hours (June-August)

○ Monday-Friday: 8:00 am - 5:00pm
○ Saturday: 8:00 am- 2:00 pm

ABA of Wisconsin’s Potter Road Center is closed on the following federally recognized holidays:
● New Year’s Day, Memorial Day, Fourth of July, Labor Day, Thanksgiving, and Christmas
Day

ABA of Wisconsin’s Potter Road Center may be open on the following days; however,
schedules and hours of operation may be modified.
● The Monday after Easter, the Friday after Thanksgiving, Christmas Eve, New Year’s Eve

Our staff members are generally available Monday through Friday from 8:00 a.m. to 5:00 p.m.
although hours may vary among staff members (please speak with your assigned clinician
therapist if you have questions/concerns about their hours). During this given time period, you

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may call to schedule appointments, ask questions, and leave messages. Please use email if
you need to correspond with our staff outside of our standard hours of operation and our staff
make their best effort to respond within 24 business hours. If you have an emergency situation,
please call 911 immediately.
If you need to contact a clinician during your participant’s therapy session, please call the front
desk and you will be routed to a staff who can best answer your question.

Arrival and Departure Policies

Arrival
Participants must arrive at the center at the scheduled time each day. On time arrival will ensure
that participants are accessing all of their allocated treatment time and allow time for parents to
communicate important information to our staff. Our staff are not available to start sessions
early or provide supervision outside of scheduled times due to other job responsibilities. If you
arrive early with your participant, you are welcome to wait in our waiting room.
Our staff will call if you are not present 10 minutes into your scheduled arrival time. ABA of
Wisconsin will allow a 5-minute grace period prior to recording an unexcused late time.

Departure
Caregivers should arrive at the center 5-10 minutes prior to the end of the participant’s day.
During this time, a clinician familiar with your participants case will provide caregivers with a
summary of the participant’s day. Caregivers should not arrive prior to 5-10 minutes before the
participant’s end of day to ensure that the participant is not distracted by the early arrival of their
caregiver. ABA of Wisconsin will allow a 5-minute grace period prior to recording an unexcused
late time for pick up.
ABA of Wisconsin’s staff will not release your participant to an unauthorized individual. All
individuals who may pick up your participant must be listed on the participant pick up
authorization form. If any changes need to be made to the authorized individuals, please
provide us with an updated list immediately. All individuals who are authorized to pick up your
participant will be required to produce a state-issued photo identification prior to participant’s
release to their care. If an individual is listed on the pick up authorization form, you are giving
consent for our therapists to provide a summary of your participant’s day to that individual. A
blank copy of the participant pick up authorization can be found at the end of this handbook or
in the waiting room.

A endance
Consistently attending scheduled ABA sessions is a critical component of treatment success
and ABA of Wisconsin reserves the right to discharge participants whose progress is impeded
by chronic cancellations.

Why is consistent attendance this important?

● Parent and participant involvement is a key component of our treatment services.

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 ● Frequent contact with our clinicians is necessary to ensure consistency and integrity of
our treatment plans and to ensure progress.
● Funders expect their participants to receive the recommended treatment on a consistent
basis to achieve desired outcomes. We are required to document attendance as part of
our participant’s records and progress reports.
● Our clinicians reserve time in their schedules to be available to their participants.
Typically cancellations cannot be filled with other appointments without advance notice.
Sickness Policy
Our sickness policy requires all participants and other individuals in the treatment setting to be
symptom free for 24 hours before participating in ABA therapy. It is important that our
participants are healthy enough to benefit from treatment sessions and that we maintain the
health of our clinicians and other participants and families who access Potter Road Center.

If any of the following symptoms are observed, we ask that you cancel your participant’s
session:
● Diarrhea (occurring more than once in a 24-hour period)
● Vomiting
● Temperature of 100.4 or higher
● Severe sore throat, headache or chronic coughing
● Any communicable or contagious disease (e.g., chicken pox, influenza, lice,
streptococcal infections)

If you need to cancel a therapy session, please contact the main line at the center as soon as
possible. Cancellations should be made 24 hours prior to the cancelled session, whenever
possible. Our scheduling team will attempt to reschedule any cancelled sessions; however, we
are unable to guarantee that cancelled sessions will be able to be rescheduled.

If a participant misses ABA therapy due to a communicable or contagious disease or illness, a

physician’s statement may be required before the participant is able to return to ABA therapy.

If any individual who was at the center within 24-48 hours of diagnosis with a communicable
disease or illness, Potter Road Center must be notified as soon as possible. If any individual at
the center may have been exposed to the illness, all participants’ families will be notified within
24 hours via email. If it is believed that any participant has been exposed to the communicable
illness, a posting of the illness name and information about symptoms associated with that
illness will be posted at the front desk.

If a participant becomes ill (see list above for symptoms) during their scheduled therapy
sessions, they will be taken to an area away from other participants and the designated
caregiver will be contacted. If staff are unable to reach the caregiver within 10 minutes of the
initial call, the emergency contact will be called to arrange for pick-up of the participant.

Inclement Weather & Other Emergency Closure Informa on

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Inclement weather, including, but not limited to, snow, storms, icy roads, storm warnings and
other emergent conditions may result in Potter Road Center closing or delays in opening until
conditions improve. Potter Road Center follows Wauwatosa School District closures, late starts,
or early closure. If Wauwatosa School District closes due to inclement weather, Potter Road
Center will also be closed. All changes to our normal operating hours will be communicated to
parents (and/or other caregivers as indicated by you on our contact list) via text message and
email as soon as possible. A recorded message will provide closure, late starts or early closure
information on the center’s main line.
In the event of inclement weather, we encourage you to use good judgment and not take undue
risks to travel to and from Potter Road Center. Ultimately, the decision to send your participant
to our Potter Road Center is yours. If you do decide to keep your participant at home due to
inclement weather when the center is open for operation, please contact us at the mainline
(262-200-0900) a minimum of two (2) hours in advance of the scheduled start time. Please
leave a voicemail if you are calling before the center’s hours of operation.

A endance
Cancellations must be made only in the case of a true illness (see list of symptoms above) or
family emergency. Vacations or other excused absences require at least two weeks of advance
notice, with more notice given whenever possible. This allows our clinicians to reschedule and
plan for the missed session time. Your participant’s ABA therapy schedule is carefully developed
based on their needs, your availability and the availability of your dedicated clinical team. ABA
of Wisconsin cannot guarantee that requested changes to established schedules can be
accommodated, and we reserve the right to suspend or terminate services if cancellations and
other schedule changes that do not align with our policies and procedures.

If chronic unexcused absences or tardiness occurs within a designated time period, (see
specific guidelines below) a meeting will be scheduled with the treatment center supervisor and
your participant’s assigned BCBA to develop a corrective action plan to decrease future
absences or tardiness. If additional absences or tardiness occur and/or a plan cannot be
developed to ensure that your participant is present for scheduled sessions, your participant
may be discharged from services with ABA of Wisconsin.

Please refer to the following definitions regarding absences and tardiness:

● Absence: Any time the participant does not attend treatment during the scheduled time.

● Excused absence: Absences that are planned and reported to the center with at least 2
weeks advance notice or a cancellation due to participant illness made by 5pm the
previous day. To call out for a session, please call Potter Road Center’s front line at
262-200-0900 and speak with the receptionist or press 3. If calling on Sunday or
outside of center hours, please call Potter Road Center’s main line and press 3.
o 9 excused absences will be allowed within the fall-spring term.
o 6 excused absences will be allowed within the summer term.

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 ● Unexcused absence: Absences that are not previously planned or are reported to the
center after 5pm the previous day, but are reported to the center prior to the missed
treatment.
o A total of 3 unexcused absences and no call/no show absences will be allowed
within the fall-spring term.
o 1 unexcused absence will be allowed within in the summer term.

● No Call/No Show: Absences that are not reported to the center, where the participant
does not arrive for the scheduled treatment.
o A total of 1 no call/no show absences will be allowed within the fall-spring term.
o A total of 1 no call/no show absence will be allowed within the summer term.

● Excused tardiness: Arrival or pick-up from a session that is between 5-15 minutes of the
scheduled start time or end time that may occur due to weather or unexpected
circumstances, with notification to the center. Caregivers should contact the center if
they will be more than 5 minutes late for arrival or pick-up.
o A total of 6 excused tardiness will be allowed within the fall-spring term.
o A total of 3 excused tardiness will be allowing within the summer term.

● Unexcused tardiness: Arrival or pick-up from a session that is more than 15 minutes
after the scheduled start time or end time.
o A total of 3 unexcused tardiness will be allowed within the fall-spring term.
o A total of 1 unexcused tardiness will be allowed within the summer term.

● Schedule Adjustments: Clients are expected to attend their full scheduled session. If a
one time schedule adjustment needs to be made (e.g., for doctor’s appointments, family
visits, etc.) they should be coordinated 2 weeks in advance. Any schedule adjustments
made with less than 2 weeks notice will be considered an unexcused absence.
o A total of 6 schedule changes will be allowed within the fall-spring term.
o A total of 3 schedule changes will be allowed within the summer term.

Excused Unexcused No Call/ Excused Unexcused Schedule

Term Absence Absence No Show Tardiness Tardiness Adjustments

Fall-Spring 9 3 1 6 3 6
(September
-May)

Summer 6 1 1 3 1 3
(June-
August)

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Please note that these are general guidelines and that all excused and unexcused absences
and tardiness will be reviewed on a case-by-case basis.

Visitor Acknowledgement & Policy

Due to your participant receiving services in a center-based environment, visitors may
occasionally be present in the therapy setting. ABA of Wisconsin’s Potter Road Center is a
secure facility and people entering the building must ring the doorbell and be buzzed in by an
authorized employee. All visitors must have prior approval to be on site.

DEFINITION:
The word visitor used in this form represents all individuals who may come into the center who
are not employees of ABA of Wisconsin or a participant in ABA of Wisconsin’s services. Visitors
may include: other parents, service coordinators or case managers, parents of prospective
participants, interviewees, or contracted workers who are unable to perform tasks before or after
center operating hours.

Visitors in the center may see your participant while walking through the center and visitors may
hear your participant’s first name. No other information regarding your participant will be shared
with visitors. All visitors will be accompanied by an ABA of Wisconsin clinical supervisor at all
times. Interviewees may interact with participants to assess their ability to interact with
participants.

Visitors in Instruc onal Areas

Access to instructional areas of the center is limited to individuals with prior approval from the
Treatment Center Supervisor. The duration of visits into therapeutic areas will be limited to
amount of time necessary for the purpose of the visit to be accomplished.

ABA of Wisconsin retains the right to refuse entrance to any visitor who is unable to produce
identification and/or is unable to verify the reason for visit. Additionally, the Treatment Center
Supervisor has the authority to ask any visitor to leave the center if disruptive or unruly. Law
enforcement authorities will be called if a visitor is unwilling to leave upon request.

Snacks and Meal Times

All snacks and meals shall be provided by participant’s caregivers. Participants should bring
their lunch daily in a labeled lunch box with cold packs. All lunches will be stored in the fridge
until the participant’s designated lunch period. Plates and utensils will be provided to
participants. Participants may bring lunches that require heating in a microwave or toaster oven.
Any food requiring microwaving, should be sent in a microwave-safe container. Caregivers are
encouraged to follow the U.S. department of agriculture child care food program minimum meal
requirements (a copy of those guidelines are included at the end of this handbook). Any
uneaten portion of the participant’s lunch will be sent home whenever possible. Staff will inform

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parents of any food refusals. Caregivers must inform staff of any dietary concerns. Participants
should bring a water bottle to drink from throughout the day. Any beverages besides water must
be brought from home.
Healthy snacks should be sent in for participants to consume throughout the day.
Non-perishable snacks may be stored at the center and must come in zip top bags or sealed
containers and be labeled with the participant’s name.
To ensure the safety of all of our participant’s ABA of Wisconsin’s Potter Road Center is a nut
free facility. Participant’s may not bring lunches or snacks containing nuts into the center. A list
of snacks that are nut-free can be found at the end of this handbook. Additionally, participants
and visitors should wash their hands before entering or immediately upon entering the center, if
nuts were recently consumed.

Toile ng and Addi onal Clothing

All participants will use the toilets and restrooms available in the center space for toileting and to
change pull-ups or diapers. When needed, toileting plans will be developed by the participant’s
treatment team and caregivers specific to their current skill level and treatment goals.
Participants who utilize pull-ups and/or diapers must bring them in from home. Participants are
encouraged to keep spare pull-ups or diapers at the center. Any pull-ups, diapers, or wipes sent
in will be kept in a labeled bin and only utilized for the intended participant.
All participants should have at least one spare change of season appropriate clothing available.
If a spare change of clothing is needed and not available, ABA of Wisconsin staff will provide
participants with a set of spare clothing, when possible. ABA of Wisconsin’s clothing should be
laundered and returned to the center. Any soiled clothing will be sent home with the participant
at the end of their session in a plastic bag for laundering. ABA of Wisconsin’s staff will notify
parents when additional clothing is required.
ABA of Wisconsin discourages participants from bringing other personal belongings from home.
If other belongs are brought, items must be labeled to help keep items from being lost. ABA of
Wisconsin cannot ensure the safety of personal items that are brought from home and waives
responsibility for lost or damaged personal property.

Napping Policy
All participants under 5 years of age who are at the center for more than 4 hours, will be given a
nap or rest period of at least 15 minutes. If it is determined that the nap or rest period is not
necessary or if interfering behaviors occur during the designated nap or rest period, the clinical
team and parent/guardian will determine if naps or rest periods are needed going forward.
All napping participants will be provided with a cot. All napping participants are required to bring
labeled bedding (e.g. blanket, sleeping bag, or pillow) to the center for use during nap or rest
periods. Bedding may be stored at the center during the week. All bedding will be sent home on
Fridays to be laundered or alternated by families or when soiled. All bedding should be sent in a
large sealable plastic bag and labeled with the participants name.

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Medica on Administra on
It is the policy of PRC to discourage the administration of medication or supervision of
self-medication to participants during scheduled sessions. Medications taken at PRC are to be
limited to those necessary during schedule session times and those needed in the event of an
emergency. The guidelines set forth in this policy do not prohibit any center employee
from providing emergency assistance to a participant. ABA of Wisconsin staff will not
administer medication to any participant, nor will any participant possess or consume any
prescription or non-prescription medication without a parent or designated caregiver present
unless the Authorization and Permission for Administration of Medication form has been filed
with PRC and appropriate training by a nurse has been provided. The Authorization and
Permission for Administration of Medication form will be completed by the participant’s
parent/guardian and licensed prescriber and reviewed by the center prior to dispensing any
medication to a participant. The Authorization and Permission for Administration of Medication
form must be completed annually and must be updated when any medication change is made.
Forms are available in the parent resource area in the waiting room, at the reception desk, and
additional forms will be provided to parents or caregivers upon request.

All medications given at PRC, including non-prescription drugs, shall be prescribed by a

licensed prescriber on an individual basis as determined by the participant’s health status. Such
written documentation will be maintained in the participant’s individual medication record.
A written order for prescription and non-prescription medications must be obtained from the
participant’s licensed prescriber. The order includes:
● Participant’s Name
● Date of Birth
● Licensed Prescriber’s Name, Signature and Date
● Licensed Prescriber’s Phone and Emergency Number(s)
● Name of Medication
o dosage
o route of administration
o frequency and time of administration
● Diagnosis Requiring Medication
● Intended Effect of the Medication /Possible Side Effects
● Other Medications participant is Receiving
● Time Interval for Re-Evaluation
● Approval for Self-Administration, if applicable
● Approval for participants to carry emergency medication on their person (i.e., inhaler, Epi
Pen), if applicable
Medication must be brought to the center in a container and labeled appropriately by the
pharmacist or licensed prescriber.
Prescription Medication
Prescription medication shall display:

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 ● Participant’s Name
● Prescription Number
● Medication Name and Dosage
● Administration Route or Other Directions
● Date and Date of Refill
● Licensed Prescriber's Name
● Pharmacy Name, Address and Phone Number
● Name or Initials of Pharmacist

Over the Counter Medication (OTC):

OTC (non-prescription) medication shall be brought in with the manufacturer's original label with
the ingredients listed and the participant's name affixed to the container.
Medication Administration Forms:
In addition to the licensed prescriber's order, a parent/guardian must submit a written request for
medication to be given during scheduled session hours. The request must include the name of
the participant, the parent(s)/guardian(s) name and phone number in case of emergency. The
written request should also indicate the name of the medication, when it is to be given, and any
special instructions for dispensing it (e.g., take with food, do not give with milk, etc.). It is the
parent’s or guardian's responsibility to ensure that the licensed prescriber’s order, written
request, and medication are brought to PRC.
Participants will be evaluated on an individual basis regarding the need to carry emergency
medication. A written statement signed by the participant’s physician and parent/guardian
verifying the necessity and participant’s ability to self-administer the medication appropriately
should be in the participant’s file, if applicable.
Medications will be stored in a separate locked drawer or cabinet. Medications requiring
refrigeration will be stored in a locked container separate from food products.
At the end of the treatment regime or after the participant is discharged from services, the
participant’s parent/guardian will be responsible for removing any unused medication. The
participant’s parent/guardian must pick up all the medication within 2 weeks of discharge.
It is PRC’s responsibility to clarify any medication order which is deemed inappropriate or
ambiguous. Prior to administering any medication PRC’s administrative team will receive
training from a nurse regarding the procedures to use for administration of medication, the
effects and potential side effects of the medication, and storage and handling of the medication.
PRC administrators have the right and responsibility to decline to administer a medication. In
such instances, PRC must notify the parent/guardian and participant’s physician immediately;
however, the parent/guardian has the right to administer it at the center.
If a medication error were to occur (i.e., giving the wrong medication dosage, giving the wrong
medication to the wrong participant, failing to give a dosage of medication, or giving medication
at the wrong time), the participant would be monitored for any signs of distress and necessary
action would be taken. The participant’s parent/guardian and licensed prescriber would be
notified immediately regarding the type of medication error that had been made. Documentation

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regarding the medication error would be recorded both in the medication log and on the PRC
incident report. Copies of both reports would be made for the parent(s) or guardian and would
also be kept in the participant’s file.

The Treatment Center Supervisor is primarily responsible for administering participant

medication. In his/her absence, the designated supervisor will assume the duties. All medication
will be provided as described in the Medication Update Form and, if applicable, the participant’s
Crisis Plan as part of their treatment plan. Each time a participant is administered any type of
medication, it will be recorded in the medication log. A copy of your participant’s medication log
will be made available upon request.
A participant has the right to refuse medication, and in some instances, may do so. In such
instances, it is the designated administrator’s responsibility to explain to the participant as fully
and clearly as possible the importance of taking the medication. If the participant continues to
refuse to comply, the parent(s) or guardian and participant’s physician must be notified.

Injury, Illness, and Incident Repor ng Policy

Injury and Illness Repor ng
ABA of Wisconsin holds the health and safety of our participants as a top priority. All ABA of
Wisconsin staff are trained in CPR and basic first aid within the first 3 months of employment
and there is always a designated CPR and first aid lead staff present at the center during all
hours of operation. At times, it may be necessary to provide minor first aid, to contact your
participant’s physician, or to seek emergency medical attention to ensure the safety and/or
health of your participant.
ABA of Wisconsin staff will document any minor injury in the injury log for your participant and
will notify you at pick up of any injuries or minor first aid that may have been provided during
that day’s session.

Basic First Aid

Basic first aid will be completed by your participant’s staff at the time needed, as trained through
American Red Cross curriculum. If first aid is required in session, ABA of Wisconsin staff will
provide a verbal update to caregivers at the time of pick up.

Contac ng Physicians
In addition to regular collaboration with participant’s physicians, ABA of Wisconsin may contact
a participant’s physician regarding any medication administration questions. For basic health
concerns, ABA of Wisconsin will always contact parents/guardians prior to contacting a
participant’s physician; however, as indicated in the medication administration policy, a
physician may need to be contacted regarding medication administration, medication side
effects, a medication error, or for other reasons related to medication administration. ABA of
Wisconsin staff will document any physician call or contact in your participant’s records. A copy
of the documentation will be made available upon request.

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Emergency Situa ons
If an emergency medical situation arises, emergency medical attention will be sought
immediately. ABA of Wisconsin’s staff will contact a parent/guardian immediately after
emergency medical responders are called. If a parent/guardian is not reached, the listed
emergency contact will be called. ABA of Wisconsin staff will complete an incident report form
for any emergency requiring medical attention. That report will be made available to
parents/guardians within 24 hours of the incident requiring medical attention.

The planned location for emergency medical care is Froedert Hospital located at 9200 W 
Wisconsin Ave, Milwaukee, WI 53226. If an alternative location for emergency medical care is
identified, a parent/guardian will be notified immediately.

Incident Repor ng
ABA of Wisconsin is unable to predict all situations that may arise that may require additional
documentation or parent notification. If any notable situation occurs outside of the injury,
medical emergency, or physical intervention policies, an incident report will be completed by the
ABA of Wisconsin staff that witnessed or was involved in the incident. Parents/guardians will be
notified at pick-up of any incident that occurred unless it is deemed by the treatment center
supervisor that immediate notification is appropriate. Parents/guardians will receive a copy of
the incident report within 2 business days of the incident occurring.

Please note that all ABA of Wisconsin staff are Mandated Reporters by the state of Wisconsin
and will follow all Mandated Reporter laws if abuse and/or neglect is suspected or observed.

Caregiver Par cipa on

Parent/caregiver and participant involvement is a key component of our treatment services.
Consistent implementation of procedures across caregivers and environments is important to
ensure effective and successful treatment. Frequent contact between our Behavior
Analysts/Therapists is necessary to ensure consistency and integrity of our treatment plans and
to relay important participant information. It is important for family members and participants to
provide input regarding treatment goals, outcomes and procedures.

Caregiver Training

To ensure parent/caregiver involvement, caregiver training sessions will be scheduled at least

monthly. During caregiver training sessions, the participant’s data towards treatment objectives
will be reviewed, parents/caregivers will have an opportunity to ask questions about
programming and to provide input on objectives. Training will be provided by the Behavior

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Analyst on how to implement the participant’s behavior support plan and/or treatment
objectives. Whenever possible, caregiver training sessions will be scheduled during participant’s
regularly scheduled sessions at PRC; however, ABA of Wisconsin acknowledges that this will
not always be possible. Caregiver training sessions that cannot be held during regularly
schedule sessions will be coordinated with participant’s parents/caregivers and their clinical
team.

Generaliza on Sessions

To ensure that our participants are able to generalize the skills they are working on at PRC to
other environments and caregivers, generalization sessions will be held at least monthly.
Whenever possible, caregiver sessions will be scheduled during our participant’s regularly
scheduled sessions; however, ABA of Wisconsin acknowledges that this will not always be
possible. Generalization sessions that cannot be held during regularly scheduled sessions will
be coordinated with participant’s parents/caregivers and their clinical team.
Generalization sessions may occur at a participant’s home, in the community, or in other
locations that are deemed appropriate by the participant’s clinical team. ABA of Wisconsin staff
are not permitted to transport participants; therefore, any participant transportation to and from a
generalization session must be provided by the parent/guardian or caregiver. During
generalization sessions caregiver objectives will be targeted. Additional information regarding
generalization sessions will be provided by the clinical team prior to the generalization session.

Restraint and Seclusions Policies and Procedures

ABA of Wisconsin uses the principles of behavior to prevent challenging behavior and teach
replacement behaviors and alternative behaviors. ABA of Wisconsin staff are trained to use the
least restrictive measures possible whenever managing challenging behaviors that may occur.
Challenging behaviors that pose no risk or limited risk to the participant, staff, and others in the
environment will always be managed without the use of restraint or seclusion procedures. The
use of restraint and seclusion is avoided whenever possible; however, may become necessary if
dangerous challenging behaviors that pose an imminent risk of safety to the participant or
others in the environment occur.
If your participant engages in challenging behavior, a behavior support plan will be developed
during the assessment phase using functional behavior assessment or functional analyses to
reduce the occurrence of challenging behavior specific to your participant. The behavior support
plan will include both preventative and reactive procedures that are based on the function of the
targeted behavior. Preventative procedures will be utilized throughout all sessions to reduce the
likelihood that challenging behavior will occur. Reactive procedures will be utilized when the
target behaviors occur. The reactive procedures developed are always the least restrictive
possible. The strategies utilized will be reviewed with you prior to implementation; however, at
times alternative strategies may be necessary. If a crisis situation occurs (as defined in your
participant’s treatment plan) or if an unsafe novel behavior occurs, restraint and/or seclusion

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procedures may be necessary to ensure the safety of the participant, staff, or other individuals
in the environment.
All ABA of Wisconsin staff who implement restraint and/or seclusion procedures are trained to
utilize Professional Crisis Management (PCM). All crisis behaviors managed with PCM crisis
intervention procedures must be occurring continuously and unable to be managed through less
restrictive approaches. PCM strategies will be utilized for the shortest amount of time necessary
to ensure safety. Your signature on the treatment plan indicates your consent for ABA of
Wisconsin to utilize PCM procedures if necessary.
If ABA of Wisconsin staff utilize restraint and/or seclusion procedures to manage crisis behavior,
caregivers will be notified via phone following the restraint and/or seclusion procedure.
Additionally, a written copy of the restraint and/or seclusion procedures utilized will be provided
to caregivers and the participant’s case manager, if applicable, within 24 hours.

Agreements
Client Bill of Rights and Responsibili es

ABA of WI, LLC believes that all client’s have the right to be informed of their rights and
responsibilities before the initiation of treatment/services.

CLIENT RIGHTS, you have the right:

● To receive services appropriate to your needs and expect that ABA of WI staff will
provide safe, professional treatment at the level of intensity needed, without unlawful
restriction by reason of age, gender, sex, sexual orientation, race, creed, color, national
origin, religion, disability or status with regard to public assistance.
● To have access to necessary treatment services during your scheduled treatment times
and within the operating hours of ABA of WI.
● To be informed of available services and the qualifications/credentials of the staff
providing these services.
● To be informed of the ownership and control of the organization.
● To be informed upon request if the organization’s liability insurance will cover injuries to
employees when they are in your home, and if it will cover theft or property damage that
occurs while you are receiving treatment.
● To be informed of ABA of WI’s, policies and procedures.

CLIENT CARE, you have the right:

● To be involved in your treatment planning, including education, from admission to
discharge, and to be informed in a reasonable time of anticipated termination and/or
transfer of service.
● To receive reasonable continuity of care.
● To be informed of your rights and responsibilities in advance concerning treatment you
will receive including any changes to the frequency of treatment/services and by whom
services will be provided.

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 ● To be informed of the nature and purpose of any assessment or treatment procedure
that will be implemented, including information about the potential benefits and risks as
well as who will perform the treatment.
● To be informed of treatment goals and progress updates in a timely manner.
● To receive treatment/service from staff that are qualified through education and/or
experience to carry out the duties for which they are assigned.
● To be referred to other agencies and/or organizations when appropriate.

RESPECT AND CONFIDENTIALITY, you have the right:

● To be treated with consideration, respect, and dignity, including the provision of privacy
during treatment.
● To have your property treated with respect.
● To receive information about your treatment in a manner you can reasonably be
expected to understand.
● To maintain confidentiality of your clinical records in accordance with legal requirements
and to anticipate the organization will release information only with your authorization or
as required by law.
● To review your clinical records and release these records to any person or organization
that you designate.
● To be informed of the organization’s policies and procedures for disclosure of your
clinical record.

FINANCIAL ASPECTS OF CARE, you have the right:

● To be informed of the extent to which payment for the treatment services may be
expected from Medicaid or any other payer.
● To be informed of changes not covered by Medicaid or any other payer and/or
responsibility for any payment(s) that you might have to make.

SELF-DETERMINATION, you have the right:

● To make decisions about your treatment plan prior to and during the course of treatment.
● To refuse all or part of your treatment to the extent permitted by law and to be informed
of the expected consequences of said action.
● To not participate in research or not receive experimental treatment unless you give
documented voluntary informed consent.
● To participate in consideration of ethical issues that may arise in your treatment.

COMPLAINTS, you have the right:

● To voice complaints/grievances about treatment or care that is (or fails to be) provided,
or regarding lack of respect for property without reprisal or discrimination for it and be
informed of the procedure to voice complaints/grievances with the organization.

CLIENT RESPONSIBILITIES

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As a client of ABA of WI, you have the responsibility:
● To provide complete and accurate information about diagnoses, disabilities, medications,
other treatment/services being received and other matters pertinent to your health; any
changes in address, phone, or insurance/payment information.
● To understand, participate in and follow your treatment plan.
● To keep your scheduled appointments and inform the organization when you will not be
able to keep an appointment in accordance with our attendance policy. ABA of WI
reserves the right to discharge clients from treatment due to lack of
attendance/participation.
● To respect the privacy and confidentiality of other clients that you might encounter in our
treatment center environment.
● To treat the staff with respect.
● To provide a safe environment for treatment to be given if services are provided in your
home.
● To cooperate with staff and ask questions if you do not understand instruction or
information given to you.
● To assist the organization with billing and/or payment issues to help with processing third
party payment.
● To inform the organization of any problems or dissatisfaction with services.

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No ce of Privacy Prac ces

THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT A

PARTICIPANT MAY BE USED AND DISCLOSED AND HOW THE PARTICIPANT CAN
GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

ABA of Wisconsin, LLC understands that we collect private and/or potentially sensitive medical
information about each participant and/or the participant’s family. We call this information
“protected health information”. This notice explains how we may use and disclose your
protected health information to carry out treatment, payment or health care operations and for
other purposes that are permitted or required by law. It also describes your rights to access and
control your protected health information. “Protected health information” is information about
you, including demographic information, that may identify you and that relates to your past,
present or future physical or mental health condition and related health care services.

ABA of Wisconsin, LLC is required by law to abide by the terms set forth in this notice. We
reserve the right to change this notice and make new provisions at any time. If our information
changes, a revised Notice of Privacy Practices will be provided to you. You may also access the
current version in our waiting room. Your protected health information will not be used or
disclosed without your written authorization, except as described in this notice. In addition you
have the right to:

1. Receive a copy of the Notice of Privacy Practices from us upon enrollment or upon
request.

2. Request restrictions on our uses and disclosures of your protected health

information for treatment, payment and health care operations. This means you may ask us not
to use or disclose any part of your protected health information for the purposes of treatment,
payment or health care operations. You may also request that any part of your protected health
information not be disclosed to family members or friends who may be involved in your care or
for notification purposes as described in this Notice of Privacy Practices. Your request must
state the specific restrictions requested and to whom you want the restriction to apply.

3. Request to receive communications of protected health information in confidence.

4. Inspect and obtain a copy of the protected health information contained in your
medical and billing records and in any other Practice records used by us to make decisions
about treatment. If we maintain or use electronic health records, you will also have the right to
obtain a copy or forward a copy of your electronic health record to a third party. A reasonable
copying/labor charge may apply.

5. Request an amendment to your protected health information. We may deny your

request for an amendment, if we determine that the protected health information or record
that is the subject of the request:

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 • was not created by us, unless you provide a reasonable basis to believe that the
originator of the protected health information is no longer available to act on the
requested amendment;
• is not part of your medical or billing records;
• is not available for inspection as set forth above; or
• is accurate and complete.

In any event, any agreed upon amendment will be included as an addition to, and not a
replacement of, already existing records.

6. Receive an accounting of disclosures of protected health information: This

right applies to disclosures for purposes other than treatment, payment or health care
operations as described in this Notice of Privacy Practices. It excludes disclosures we may
have made to you if you authorized us to make the disclosure to family members or friends
involved in your care, or for notification purposes, for national security or intelligence, to law
enforcement (as provided in the privacy rule) or correctional facilities, as part of a limited
data set disclosure. You have the right to receive specific information regarding these
disclosures that occur. The right to receive this information is subject to certain exceptions,
restrictions and limitations.

7. Revoke your authorization to use or disclose health information except to the

extent that we have already taken action in reliance on your authorization, or if the
authorization was obtained as a condition of obtaining insurance coverage and other
applicable law provides the insurer that obtained the authorization with the right to contest a
claim under the policy.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Your protected health information may be used and disclosed by your clinician, our
administrative staff and others outside of our office who are involved in your care and treatment
for the purpose of providing health care services to you. Your protected health information may
also be used and disclosed to pay your health care bills and to support the operation of ABA of
Wisconsin, LLC’s practice.

The following are examples of the types of uses and disclosures of your protected health
information that ABA of Wisconsin, LLC is permitted to make. These examples are not meant to
be exhaustive, but to describe the types of uses and disclosures that may be made.
*All references to “you” or “your” refer to both you and your child, if you are a parent or legal
guardian of a child or children receiving ABA Services.

ABA of Wisconsin, LLC may use and/or disclose your clinical information for the following
purposes:

Treatment: We may use and disclose protected health information in the provision,
coordination, or management of your health care, including consultations between healthcare

22
providers regarding your care and referrals for health care from one healthcare provider to
another.

Military and Veterans: If you are a member of the armed forces, we may release protected
health information about you as required by military command authorities.

Lawsuits and Disputes: We may disclose protected health information about you in response
to a court or administrative proceeding.

Payment: We may use and disclose protected health information to obtain reimbursement for
the health care provided to you, including determinations of eligibility and coverage and other
utilization review activities.

Regular Healthcare Operations: We may use and disclose protected health information to
support functions of our practice related to treatment and payment, such as quality assurance
activities, case management, receiving and responding to participant complaints, physician
reviews, compliance programs, audits, business planning, development, management and
administrative activities.

Appointment Reminders: We may use and disclose protected health information to contact
you to provide appointment reminders.

Individuals Involved in Your Care or Payment for Your Care: Unless you object, we may
disclose your protected health information to your family or friends or any other individual
identified by you when they are involved in your care or the payment for your care. We will only
disclose the protected health information directly relevant to their involvement in your care or
payment. We may also disclose your protected health information to notify a person responsible
for your care (or to identify such person) of your location, general condition or death.

Business Associates: There may be some services provided in our organization through
contracts with Business Associates. Examples include our third party billing agency and our
clinical software company. When these services are contracted, we may disclose some or all of
your health information to our Business Associate so that they can perform the job we have
asked them to do. To protect your health information, however, we require the Business
Associate to appropriately safeguard your information.

Worker's Compensation: We may release protected health information about you for programs
that provide benefits for work related injuries or illness.

Communicable Diseases: We may disclose protected health information to notify a person

who may have been exposed to a disease or may be at risk for contracting or spreading a
disease or condition.

Health Oversight Activities: We may disclose protected health information to federal or

state agencies that oversee our activities.

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Law Enforcement: We may disclose protected health information as required by law or in
response to a valid judge ordered subpoena. For example in cases of victims of abuse or
domestic violence; to identify or locate a order. We may also disclose medical information about
you in response to a subpoena, discovery request, or other lawful process.

Abuse or Neglect: We may disclose protected health information to notify the appropriate
government authority if we believe a participant has been the victim of abuse, neglect or
domestic violence. We will only make this disclosure if you agree or when required or
authorized by law.

Fundraising: Unless you notify us you object, we may contact you as part of a fundraising
effort for our practice. You may opt out of receiving fundraising materials by notifying the
practice’s privacy officer at any time at the telephone number or the address at the end of this
document. This will also be documented and described in any fundraising material you
receive.

Coroners, Medical Examiners, and Funeral Directors: We may release protected health
information to a coroner or medical examiner. This may be necessary to identify a deceased
person or determine the cause of death. We may also release protected health information
about participants to funeral directors as necessary to carry out their duties.

Public Health Risks: We may disclose your protected health information for public health
activities and purposes to a public health authority that is permitted by law to collect or
receive the information. The disclosure will be made for a purpose such as controlling
disease, injury or disability.

Serious Threats: As permitted by applicable law and standards of ethical conduct, we may
use and disclose protected health information if we, in good faith, believe that the use or
disclosure is necessary to prevent or lessen a serious and imminent threat to the health or
safety of a person or the public.

Research: We may disclose information to researchers when an institutional review board

that has reviewed the research proposal and established protocols to ensure the privacy of
your health information has approved their research.

COMPLAINTS
If you have questions about this notice or would like additional information, you may contact our
HIPAA Compliance Officer. You may find this information on our website
www.abaofwisconsin.org. If you believe your privacy rights have been violated by us you may
complain to us or to the United States Secretary of Health and Human Services. You may file a
complaint with us by notifying our HIPAA Compliance Officer of your complaint. We will take no
retaliatory action against you if your make such complaints.

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Contact Information:
U.S. Department of Health and Human Services
Office of the Secretary
200 Independence Avenue, S.W.
Washington, D.C. 20201
Tel: (202) 619-0257
Toll Free: 1-877-696-6775
http://www.hhs.gov/contacts

Photography Consent

I understand that it may be necessary to photograph my participant for the purpose of applied
behavior analysis (ABA) assessment and/or treatment sessions. This may include photography
for staff supervision purposes. In the event that photography of my participant is necessary, I will
be informed of the specific purpose. I understand that the recorded material will be used only by
ABA of Wisconsin and only for purposes described above. If the assessment or treatment
involves formal research that goes beyond standard evaluation or clinical procedures, I reserve
the right to consent or refuse to participate.

DEFINITION:
The word photograph used in this form represents all forms of visual or audiovisual reproduction
of an individual’s likeness. This shall include, but not be limited to: film, videotape, and other
electronic reproductions.

I understand that the photograph(s)/name(s) shall be utilized only to the extent that it is
necessary to accomplish the purposes stated above.

I understand that I may revoke this consent at any time (revocation must be in writing).

I further understand that no revocation of this consent shall be effective to prevent disclosure of
records and communications until received by the person otherwise authorized to disclose
records and communications.

Service Agreement

The following information is intended to help answer some questions that you may have about
ABA of Wisconsin, LLC’s services and policies. If you have questions about the information
below, especially in how it applies to your individual case, please do not hesitate to ask.

FAMILY AND PARTICIPANT INVOLVEMENT:

The following outlines our requirements for family and participant involvement related to our
services:

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 ● A parent or designated caregiver (18 or older) must be present in the home during all
home visits. ABA of Wisconsin, LLC is not liable for anything that occurs if you do not
comply with this requirement.

● All family members/caregivers are required to participate in training to implement

procedures for behavior interventions and teaching positive behavior. Family
members/caregivers are expected to implement these procedures independently
following training. To the extent in which a participant can be involved in treatment
planning, they will be required to participate.

● Parents may be asked to purchase/supply materials for therapy sessions.

● Parents are expected to make the participant available for the clinically recommended
number of hours of treatment.

● ABA of Wisconsin Behavior Analysts, Therapists and Technicians provide written

updates on participant progress and comprehensive progress reports on a six month
schedule. Parents are encouraged to review these reports thoroughly and provide
feedback.

INFORMED CONSENT/CONFIDENTIALITY:

We keep a record of our participants’ information. This record contains the dates of contact with
our participants, notes on participant progress and other documents related to participant
treatment. This record is confidential and may be released only with written consent by the
participant/parent/guardian. ABA of Wisconsin, LLC abides by HIPAA regulations regarding
confidentiality. To release information to a third party, ABA of Wisconsin must receive a signed
“Release of Information” form from the participant/parent/guardian. ABA of Wisconsin shares
information within the organization on an as-needed basis to facilitate case collaboration, peer
review, as well as for supervision and billing purposes.

PARTICIPANT / PROVIDER RELATIONSHIP:

To maintain a professional relationship between our providers and participants it is our policy
that ABA of Wisconsin staff are not permitted to engage in ongoing social relationships, giving of
gifts, or participation in personal events such as parties, graduations, etc. Conversations
between staff members and family members are necessary, but should be limited in duration
and content. ABA of Wisconsin staff members are not permitted to provide any other services
(such as child care, respite, personal care services) outside of the scope of treatment outlined
above. If ABA of WI staff feel another service is needed that is outside of the scope of
treatment, he/she will make a referral to a qualified professional and/or to the participant’s
Service Coordinator if applicable. ABA of WI staff members are not permitted to provide
supervision to any other person (e.g. participant’s family members, siblings) besides the
participant(s) for whom they have been authorized to provide treatment. In addition, staff are
not responsible for ensuring the safety of others in the treatment settings. To ensure a safe and
harassment free therapy environment, ABA of Wisconsin prohibits any offensive, physical,

26
written or spoken conduct of a sexual or derogatory nature or based on any other characteristic
protected by law.

COMPLAINT RESOLUTION PROCESS:

It is our goal to ensure that all complaints are addressed and rectified in a timely manner.
Whenever possible you should first attempt to resolve a complaint directly with the staff
involved. You may file a formal complaint at any time within 45 days of the occurrence. The
complaint may be expressed verbally or in writing. You will not be discriminated against in any
way for reporting a complaint. Please contact the Director of Clinical Services (Amelia
McGoldrick) at 331-481-9616 or [email protected]. A formal complaint will be
documented in writing, all parties involved will be contacted to resolve the complaint and a
written summary will be completed to outline all actions to be taken to resolve the complaint. If
the complaint has not been resolved to your satisfaction, contact Karen Harper (Owner, ABA of
Wisconsin, LLC) at 630-709-5910.

Access to WiFi
ABA of Wisconsin clinicians request use of your home’s WIFI to perform essential duties related
to your participant’s treatment. These duties may include accessing your participant’s electronic
clinical records, data collection and obtaining your signature on consents or other required
forms. Please indicate whether you are willing to allow our clinicians to access your home’s
WIFI.

Workplace Health and Safety

During home based sessions,Your home is our employee’s workplace. ABA of Wisconsin, LLC
is committed to providing a safe and healthy workplace and to promoting the health and
wellbeing of its employees. As such, we require the following:

Smoke-Free Environment: Per Wisconsin’s Smoke Free Workplace law, smoking, including
e-cigarettes, vapor, etc. is prohibited in all our service environments while services are being
rendered, including the Potter Road Center, participants’ homes and community environments.

Weapons: All weapons are prohibited on PRC premises and must be secured in a safe place in
all other service environments.

Pets: We request that all pets are contained in a separate area while our employees are in your
home unless arrangements have been made with your assigned clinicians.

Statement of Non-Discriminatory Practices: ABA of Wisconsin, LLC will treat all participants
and their families with equality in a welcoming manner that is free from discrimination based on
age, race, color, creed, ethnicity, religion, national origin, marital status, sex, sexual orientation,
gender identity or expression, disability, veteran or military status, or any other basis prohibited
by federal, state, or local law.

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Please initial the following lines to indicate that you have read and agree to the following
policies and procedures.

____ I agree to follow the attendance policy and guidelines for excused and unexcused
absences and tardiness.

____ I accept that visitors may be present in the center during some of my participant’s services
at ABA of Wisconsin’s Potter Road Center.

____ I have read and understand ABA of Wisconsin’s medication administration policy.

____ I accept ABA of Wisconsin’s injury, illness, and incident reporting policy and agree to allow
ABA of Wisconsin staff to provide basic first aid and seek emergency medical care if needed.

____ I acknowledge that I have received a copy of ABA of Wisconsin, LLC’s Notice of Privacy
Practices. I further acknowledge that I have reviewed and understand the information presented
in this notice, including the appropriate contact information for the party I should contact in the
event I have any further questions, concerns, requests, or complaints regarding of the covered
subject matter.

____ I have read and consent to have my participant photographed by ABA of Wisconsin staff
for the purposes stated above.

____ I have read and agree to ABA of Wisconsin’s Service Agreement.

____ I accept ABA of Wisconsin’s complaint resolution policies.

____ I agree to allow ABA of Wisconsin’s clinicians to access our home’s Wifi during the course
of intake and/or therapy sessions.

My signature below indicates that I am the legal guardian for the participant listed above,
and that I understand and agree to the policies as outlined in this handbook.

___________________________________________________
Participant's Name

___________________________________________________ ____________
Signature of Parent or Legal Guardian (legally authorized representative) Date

____________________________________________________
Printed Name of Parent or Legal Guardian (legally authorized representative)

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