The following questionnaire is to be completed by the client's parent or legal guardian. This form has been designed to provide essential information before your initial appointment in order to make the most productive and efficient use of our meeting. Please feel free to add any additional information that you think may help us to get to know your child. Ausblick Therapie GmbH / Ausblick Therapie BV will hold information provided by you strictly confidential, and it will only be released in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and the European General Data Protection Regulation (GDPR) guidelines and as mandated by the host-nation laws.

Help Us Practice Being a Neuro-Affirmative Organization!

We believe everyone should decide on the terms that best describe their experiences. This includes our Clients and/or their Legal guardians. We aim to respect everyone's dignity and maintain professionalism in our actions and words. Here's what you should know:

Person-First Language:This type of language emphasizes the person, not the disability ('person with autism‘). It emphasizes the person and views the disorder, condition, or disability as only one part of the whole person. Some people including neurodiverse advocates, find this separates the disability too much from a person's identity. The American Psychological Association recommends using 'person-first language' to reduce bias.

Identity-First Language: This approach sees disability as a meaningful part of a person's identity. ('autistic person‘). This shows the disability is a meaningful part of someone's identity and encourages direct conversation about disability-related challenges. Some advocates in the disability community, including neurodiverse activists, feel that 'identity-first language‘ is more fitting. They believe their disability is a key part of who they are.

Euphemisms: These are softer words or phrases, like 'differently-abled'. They are often avoided because they can distract from the realities of disability.

Now, your preferences matter to us. Your responses will guide us in providing the best tailored care for your child.

This Agreement is effective from the date that it was signed and is between:

The “Provider”
Ausblick Therapie GmbH
Kaiserstraße 56
66862 Kindsbach

The “Client”
Child’s name:
Child’s date of birth:
Legal guardian name 1:
Legal guardian name 2:
Insurance: Tricare Prime
Address: ,

The Provider and the Client are referred to collectively as the “Parties”. The Parties agree as follows:

This agreement outlines the mutual understanding between the parties for the provision of Applied Behavior Analysis (ABA) and Occupational Therapy (OT) services. The client recognizes the inherent variability in therapeutic outcomes and acknowledges that while every effort will be made to deliver effective services, specific results cannot be guaranteed.

It is explicitly stated that before starting the treatment, the client must inquire with his health insurance company whether it will cover the costs or a part of the costs. It is hereby stated that the provider does not promise that the treatment costs will be covered by the health insurance company.

This Agreement shall commence from the Effective Date and remains in effect until either party terminates this Agreement.

Clients allow the Provider to bill the insurance directly on the Client’s behalf, in which case the Client also agrees to pay any service fees that are not reimbursed by the insurance, including annual deductibles, monthly copays, and cost-shares within 30 days of date of invoice.

Reminders of overdue payments will be issued 30 days and 45 days after the invoice date. After 60 days, services will be placed on hold pending processing of all overdue payments. After 90 days, the Provider reserves the option to send invoices to collection.

Even though the Provider will verify eligibility and benefits, Clients should be advised that an Explanation of Benefits (EOB) provided by an insurance carrier is never a guarantee of payment. In some cases, certain claims may be denied as “non-covered” services or there might be copay fees. In these cases, the Client agrees to pay for all previously provided “non-covered” services.

The Provider bills in 15-min units for most services, as listed in the tables below, according to the American Medical Association’s Current Procedural Terminology (CPT).

Billing for services is based on individual support and treatment plan adjustments in 15-minute units.

The preparation of a treatment plan (cpt code 97151) is charged at a flat rate.

Modification to the treatment (cpt code 97155) plan may incur costs even without the client being present.

The following costs are charged per unit:

CPT	ABA Service Type	Units	€ / Unit (Net)	€ / Unit (19% VAT included)
97151	Behavior Identification Assessment	Per Assessment	720.00	856.80
97153	Adaptive Behavior Treatment by Protocol with BCBA	15 min	45.00	53.55
97153	Adaptive Behavior Treatment by Protocol with RBT	15 min	21.25	25.29
97155	Adaptive Behavior Treatment by Protocol Modification	15 min	45.00	53.55
97156	Family Adaptive Behavior Treatment Guidance	15 min	45.00	53.55
97157	Multiple Family Group Adaptive Behavior Treatment Guidance	15 min	Free	Free
97158	Group Adaptive Behavior Treatment by Protocol Modification	15 min	15.00	17.85
-	General Hourly Rate (ESDM)	60 min	140.06	166.67
-	3-Month Programme (ESDM)	Flat fee	840.34	1,000.00
-	6-Month Programme (ESDM)	Flat fee	1,680.67	2,000.00
-	9-Month Programme (ESDM)	Flat fee	2,521.01	3,000.00

Services that are not covered by the insurance but are provided by the Provider without additional charge include:
- Travel times to and from home and community settings
- Administrative services such as scheduling and billing
- Development of program materials

The Provider bills in 15-min units for most services, as listed in the tables below, according to the American Medical Association’s Current Procedural Terminology (CPT).

Services that are not covered by the insurance but are provided by the Provider without additional charge include:
- Travel times to and from home and community settings
- Administrative services such as scheduling and billing
- Development of program materials

Scheduling

To ensure a balanced delivery of services throughout the week, Client schedules remain relatively fixed during the authorized treatment period. The Provider will strive to assign session times that optimize the learning process by taking into consideration naptime, school hours, etc. If a schedule change is required, the Client should communicate requests to their therapists or the Clinical Director at least 2 weeks prior to the desired change. Changes will be granted on a space-available basis.

Cancellations

The client is requested to notify any cancellation at least 24 hours in advance, except in case of emergency and/or illness. If the client fails to cancel with 24 hours' notice, they will be liable to a cancellation fee equal to 25% of the cost that would have been charged for the cancelled session. In addition, for services provided at home, the client may be charged for travel expenses, which will be calculated based on German tax laws. The cancellation is subject to VAT.

Should you need to cancel your child's session, please email the following email address:

Amberg location: amberg-cancellations@ausblick-therapie.de
Kindsbach location: Kindsbach-cancellations@ausblick-therapie.de
Hochheim location: hochheim-cancellations@ausblick-therapie.de
Stuttgart location: stuttgart-cancellations@ausblick-therapie.de
Grafenwöhr location: grafenwoehr-cancellations@ausblick-therapie.de
Mons location: mons-cancellations@ausblick-therapie.de

When you send an email here, all therapists will automatically be notified, eliminating the need to text the therapist directly.

Should you text your therapist to cancel, they will redirect you to send an email to the above address.

Please note, this is for ABA and OT sessions ONLY! Speech Therapy services are provided by our partner companies, and therefore speech therapists need to continue to be notified separately.

In your email, please include:
Your child's name
The reason for cancellation (illness, vacation, emergency, etc.)
When you expect your child to return to services

You will receive a response confirming receipt of the cancellation notice from either the case manager or an administrator.

If the Provider cancels a session, the Client will be notified as soon as possible. If feasible, the missed session may be made up at the first convenient opportunity for both Parties.

Late Arrival and Pickup

The Client should arrive for sessions promptly. When starting late, sessions cannot be extended to make up for missed time. If a delay in the start time of sessions is the fault of the Provider, the Client will not be billed for the delay. If the Client arrives more than 20 minutes late without prior notice, the Provider will cancel the session and bill the Client a 24-hour cancellation fee.

The Client should arrive 10 minutes before session ends to allow the Provider to discuss the outcomes of the session and therapy notes! Your delay in picking up your child from the session will affect the session time of another child. If a Client is late to pick up their child at the end of the therapy session, Client shall privately pay for additional time at the therapy rate on a quarter hour basis. This time cannot be billed to the Client’s insurer.

Repeated failures to attend scheduled sessions or consistent late arrivals to scheduled sessions/pick up times may result in termination of services.

Regular participation in scheduled ABA therapy sessions is essential for treatment success. Please note:

ABA sessions cannot be held open if a child is absent for longer than two weeks (e.g., during school holidays or for other reasons).

In case of extended absence, we reserve the right to allocate the time slot to another client in order to use therapy capacity effectively.

After returning from an absence, we will make every effort to offer suitable new time slots. However, there is no entitlement to the original schedule.

In the event of inclement weather, the Provider will follow the guidelines set forth by local U.S. Department of Defense schools. Home sessions cancelled by the Provider due to inclement weather will be rescheduled. Center-based sessions cancelled by the Client due to inclement weather will not be subject to cancellation fees.

All sessions will be cancelled for cold symptoms (sore throat, cough, atypical nasal congestion including green/yellow mucus, fever ≥100.4° F / ≥38° C) and for other potentially contagious symptoms (including vomiting, diarrhea, and conjunctivitis).

- Clients will not be admitted to the center, and a cancellation fee will not be charged.
- If a student develops these symptoms during center-based sessions, caregivers will be notified immediately and required to pick up their child early.
- If another member of the household has these symptoms during home-based sessions, sessions will be similarly cancelled.

Sessions will resume as soon as:

- Affected persons are symptom free without medication for 24 hours, and

Exceptions to this policy, including earlier admission, may be granted on a case-by-case basis (e.g., for a cough caused by allergies or a lingering cough caused by a cold after a student is no longer likely contagious).

Telehealth services may be offered by the Provider on a temporary basis (e.g., due to illness- or weather-related closures) or an ongoing basis (e.g., due to transportation logistics). Both the risks of telehealth (e.g., data breaches; poorer results) must be balanced against the attendant risk of not using telehealth (e.g., service gaps).

The type of services to be provided via Telehealth are parent training and/or direct services (if possible and allowed by the Client’s funding source). These services are not the same as a direct patient/healthcare provider visit, because the Client will not be in the same room as the healthcare provider performing the service.

There are potential risks to the use of teleconferencing technology, including but not limited to interruptions, unauthorized access by third parties, and technical difficulties. Moreover, individuals other than the Client’s therapist may be present during Telehealth service to operate audiovisual equipment, if necessary.

The Client has the right to request the following:

- Information on the videoconferencing technology
- Omission of specific details of of the Client record that are personally sensitive
- Non-clinical personnel to leave the Telehealth room at any time if not mandated for safety
- Termination of the service at any time

The Client shall note that:

- Telehealth sessions may not be audio or video recorded by any party unless agreed in advance.
- It is the responsibility of the Telehealth provider to conclude the service upon termination of the video conference connection.
- Telehealth services will be discontinued if the Client does not show up without advanced notice for 2 consecutive Telehealth appointments.

For therapy services provided in the Client’s home, adult caregivers must be present for the duration of the entire therapy session. When therapists deliver services in the Client’s home, it becomes their work environment. Therefore, the Client is required to maintain a safe and sanitary environment conducive to therapy. The Provider will cancel or terminate sessions if the environment presents any acute or chronic hazards, including by tobacco smoke, or the environment is otherwise unsuitable for therapy (e.g., due to construction).

For all therapy services provided in an out-of-office setting including but not limited to the Client’s home, community locations, and school or day care facilities, the Client hereby waives any and all liability against the Provider for all damages, costs, claims and disputes related to services provided by the Provider in the out-of-office locations.

The Provider kindly asks that the Client not give presents to employees to avoid possible influence on their clinical decisions and judgment. Employees may only accept gifts if unsolicited, valued at no more than 5 euros, and they do not give the appearance that the Client is entitled to preferential treatment, better scheduling or prices, more frequent services, or improvement of other terms.

Grievances can be addressed internally and/or externally. For minor grievances, the Client is encouraged to first pursue a resolution with the Client’s therapists or the Provider.

If internal remediation is unsatisfactory or the Client prefers to bypass internal remediation, grievances may be addressed to a relevant professional organization and/or funding source.

Codes of conduct are separately developed and enforced by each profession. For ABA, professional conduct is overseen by the Behavior Analyst Certification Board (BACB); for OT, the National Board for Certification in Occupational Therapy (NBCOT) and the American Occupational Therapy Association (AOTA); and for SLP, the American Speech-Language-Hearing Association (ASHA). The Client can review the respective codes of conduct as well as report suspected violations at:

Profession	Organization	Filing a Complaint
ABA	BACB	https: /www.bacb.com/ethics-information
OT	NBCOT	https: /www.nbcot.org/en/Public/Voice-A-Concern
OT	AOTA	https: /www.aota.org/Practice/Ethics/Complaint.aspx

The Client may also address grievances to their funding source. If the Client’s funding source is not listed below, the Client can request contact information from the Provider.

Funder	Filing a Complaint
Aetna	https://www.aetna.com/individuals-families/member-rights-resources/complaints-grievances-appeals.html
Blue Cross Blue Shield FEP	https://www.fepblue.org/contact-us
Cigna	Call Customer Service at the number on your Cigna ID card
Tricare	https://www.tricare.mil/ContactUs/FileComplaint

Either Party may terminate this Agreement for any reason, including breach by either Party or without reason, by providing verbal or written notice to the other Party.

The Client hereby voluntarily applies for and consent to services from the Provider, as described and authorized above. This consent applies to both child and legal guardian. Because the Client has the right to refuse services at any time, the Client understands and agrees that continued participation implies voluntary informed consent.

List five things that, given our services, you would like for your child to do more of and less of in order of priority.

Select all behaviors below that you have observed with your child as well as their frequency. This will help us prepare better and design a safe environment.

CLIENT CONFIDENTIALITY AND MANDATED REPORTING

Under the host nation General Data Protection Regulation (GDPR), the Provider is required to keep all client disclosures and communications confidential, except for these exceptions:

- where the Legal Guardian has authorized a release of information;
- where information is necessary for payment for services rendered;
- where such information is necessary for the Provider to defend against a malpractice action brought by the Client / Legal Guardian;
- where the Provider needs to obtain a professional consultation;
- where the client / legal guardian is examined pursuant to a court order;
- where child neglect or abuse is known or reasonably suspected; or
- where an immediate threat of physical violence against a readily identifiable victim is disclosed to the Provider.

In the course of center-, school-, or community-based therapy, others might indirectly gather basic information about the client (e.g., the client’s name). The Provider will make reasonable attempts to avoid disclosure (e.g., conversing with the Client / Legal Guardian out of the earshot of others in the center). In turn, the client / legal guardian is asked to respect and protect the privacy of other clients. In particular, the Client / Legal Guardian may directly solicit information from other Clients / Legal Guardians (e.g., exchanging phone numbers to arrange playdates) but will not solicit the Provider for this information.

Patient information on data information on data protection

According to the European General Data Protection Regulation (GDPR), the Provider is obliged to inform the Client / Legal Guardian about the purposes for which the Provider collects, stores, and transmits data as well as the clients / legal guardians rights with regards to data protection.

Responsible for data processing: Name: Ausblick Therapie GmbH
Address: Kaiserstr 56, 66862 Kindsbach
Contact: Veneta Dimitrova (data-privacy@ausblick-therapie.de)

You can reach the responsible data privacy officer with the contact information above.

Purpose of the Data Processing

To provide treatment to the Client, the Provider must create a patient file and process personal data (basic data and health data). This is not only specified by law but is also indispensable for the quality of treatment. The health data specifically protected by law include findings, anamnesis, diagnoses, and therapy suggestions collected by the Provider and other medical providers.

The Provider will only transfer the Client’s personal data to third parties if permitted by law. If the Legal Gardian has consented, the Provider may also use Client data for certain purposes other than treatment, like practice mailings, information, and reminders that concern the Client.

Recipient of Client Data

The Provider will only transfer the Client’s personal data to third parties if permitted by law. Recipients of the Clients / Legal Guardians personal data can be referring doctors, physicians, psychologists or psychotherapists, health insurance referral offices, health insurance medical review teams, health insurance funding and claim departments, medical chambers, private medical clearing houses, health insurance auditing teams, and in the case of Tricare beneficiaries, the Defense Health Agency (DHA).

Transmission is primarily for the purpose of billing the services provided to the Client and clarifying medical issues and questions arising from the Clients / Legal Guardians insurance relationship. In individual cases, data will be transmitted to other authorized recipients. In the case of American clients, billing is usually carried out via U.S. health insurance companies (i.e., the data is transmitted to recipients in the U.S. who are not required to follow the GDPR regulations); however, these companies are required to be compliant with the Health Insurance Portability and Accountability Act (HIPAA).

Storage of Client Data

The Provider is legally obliged to keep Client / Legal Guardian personal data for 10 years after completion of the treatment.

Client / Legal Guardian Rights

The Client / Legal Guardian is entitled to:
- obtain information about personal data,
- have incorrect data corrected,
- request deletion or restriction of processing of personal data under certain circumstances,
- object to the processing of personal data, and
- transfer of personal data to other specified parties (given separate consent for this purpose).

If the Legal Guardian has consented to transfer and further processing of personal data to doctors or psychotherapists involved in the treatment, the Legal Guardian may revoke consent for future processing.

Questions about the contents of this section on data protection, in particular about the scope and type of Client / Legal Guardian data, the legal basis of the processing, or the possibilities to lodge an objection and the consequences thereof, the Client / Legal Guardian is welcome to contact the Person Responsible for Data Processing.

The Client / Legal Guardian has the right to contact the competent data protection supervisory authority if of the opinion that the processing of the Clients / Legal Guardians personal data is not lawful. The address of the supervisory authority responsible is:

Landesbeauftragter für Datenschutz und Informationsfreiheit Rheinland-Pfalz,
Postfach 30 40,
55020 Mainz

*To administer any prescribed medications, the Provider must receive training or written instructions from the Client’s doctor or nurse.

Given consent from the Legal Guardian, the Provider may record multimedia of the Client, Client’s data or creative products. Because caregivers are not present at most center-based sessions, multimedia recordings help the Provider to share the Client’s progress as well as the interventions responsible for progress. These same recordings can help the Provider coordinate care among the Client’s therapists as well as train other current and future staff. On occasion, recordings may be deemed valuable for training other professionals not employed by the Provider (e.g., in lectures or workshops). Additionally, we may take photos of Client’s arts and crafts to add to our Facebook page or newsletter.

The Legal Guardian agrees to release and hold harmless the Provider from and against any and all claims, demands, actions, complaints, suits, or other forms of liability that shall arise out of or be caused by the release and use of the electronic/digital/print medium of:

(Please, mark the ones that you give consent to)

The Legal Guardian authorizes the use and sharing of treatment and service information for the purposes of continuity of care, progress report and evaluation, and professional consultation with the...