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New Patient Registration Form
Get new patient records with this new patient registration form online. Fast registrations will make your life easier.
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    • Male
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    • Single
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    Please Select
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    • United States
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
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    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
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    • Bermuda
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    • Bosnia and Herzegovina
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    • Burkina Faso
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    • Canada
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    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
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    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curacao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
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    • Eritrea
    • Estonia
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    • Gabon
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    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
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    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
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    • Iceland
    • India
    • Indonesia
    • Iran
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    • Kenya
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    • North Korea
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    • Kosovo
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    • Laos
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    • Marshall Islands
    • Martinique
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    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
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    • Mozambique
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    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
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    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
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    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
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    • South Sudan
    • Spain
    • Sri Lanka
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    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
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    • Turkmenistan
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    • Tuvalu
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    • Vatican City
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    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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    Please list all medications (DRUG NAME, DOSE, FREQUENCY, ROUTE) that you are currently prescribed, if more than one, separate them with a comma.
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    Please list all allergies, If there are no allergies indicate N/A
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     (If you do not wish to release information to any individual type n/a in each box)
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    Please note this form is required if you desire to have services in any center or public location outside of the child's home. If you wish to release medical information to anyone at this location include their information in the previous Authorization for the use and disclosure of Protected Health Information form.(If you do not wish to hold services in any location other than your home type n/a in each box)
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  • 29

    Telehealth Consent Form:

    In response to the current COVID-19 pandemic and efforts to socially distance wherever possible certain insurance funding sources are now allowing immediate telehealth/ remote services for Direct 1:1 Therapy, Parent Consultation and Supervision. 


    Definition: Telehealth, telemedicine, and related terms generally refer to the exchange of medical information from one site to another through electronic communication to improve a patient’s health. Electronic communication will vary between insurance agencies, some allow phone calls while others require a face to face video component.


    If you are receiving this notice you have the option of consenting to receiving “Synchronous interaction” telehealth services which means a real-time interaction between a patient and a health care provider located at a distant site. This applies to Direct 1:1 Therapy, Parent Consultation and Supervision/oversight of the direct therapy team and ABA programming. Restrictions may apply per your insurance plans guidelines and this benefit may need to be verified with your insurance plan before telehealth may begin.

    If you wish to consent to telehealth remote services such as telephone and video conferencing option’s please do so by choosing Yes and signing and dating below. If you do not consent to telehealth services choose No and sign and date below.

    Purpose and Benefit 

    The purpose of the tele-health consultation is to enable clients living in rural, underserved, and/or times of national emergencies (i.e., social distancing due to health crisis) to obtain access to specialists without the time, expense, or exposure of such conditions.

    Confidentiality 

    Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the tele-health consultation. All existing confidentiality protections under federal and state of California law apply to information disclosed during this tele-health consultation.  The consultation is conducted using HIPAA compliant video software.  Under conditions of national emergencies (i.e., social distancing due public and community health crisis) regulations and policies provided by HIPAA may be relaxed or not enforced.  Under such conditions, provider may use “popular” technology (e.g., facetime, Facebook, google hangouts, RingCentral, or skype etc) to conduct or perform telehealth consultation.

    Risks and Consequences

    The telehealth consultation will be similar to routine BCBA/ or Associate Supervisor supervision, except interactive video technology will allow you to communicate with the BCBA/Associate Supervisor at a  distance, and will allow the BCBA/Associate Supervisor to observe the paraprofessional (e.g., RBT, ABAT, behavior technician) working with your son/daughter and provide feedback at a distance.  The use of video technology to deliver behavioral healthcare and educational services is a new technology and may not be equivalent to direct client to provider contact.  The risks to you and/or your child due to participating in telehealth include, but are not limited to, interruptions, unauthorized access by third parties, and technical difficulties. 

    Risks and Consequences of Direct Therapy via Telehealth

    The use of video technology to deliver behavioral healthcare and educational services is a new technology and may not be equivalent to direct client to provider contact. The risks to you and/or your child due to participating in telehealth include, but are not limited to, interruptions, unauthorized access by third parties, and technical difficulties. Additional risks include physical barriers that do not allow staff to physically prompt the member, to reduce this barrier we ask that parents accompany their children during any direct therapy telehealth sessions and assist in physical prompting and guidance of the member per the Behavior Technicians guidance. If at any time the caregiver wishes to cease telehalth direct 1:1 services or if they dont believe it is beneficial they may imidiately terminate. Please contact scheduling with any concerns or any requests for termination of telehealth direct 1:1 therapy performed by the behavior technician. Scheduling contact:714-720-7733. You may also notify the supervisor assigned to your case.

    Rights

    You may withdraw consent for any telehealth session or consultation at any time without impact on your right to future care and treatment, or without risking withdrawal from program benefits to which you would otherwise be entitled.

     We will ask you to specify which services you desire via telehealth before we schedule telehealth/virtual sessions. You can choose to only recieve Supervision and Parent Consultation via telehealth and to not receive Direct 1:1 therapy, or any mix of the 3 services or none.

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    Do You Consent to receiving any telehealth service as described on the previous page?
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  • 31
    Legal Guardian Signature
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  • 32

    COVID-19 Waiver and Release of Liability Form: Morning Star ABA Therapy LLC.


    Services: Behavioral Health Treatment (BHT) Services
    I, ON BEHALF OF MYSELF AND MY DEPENDENTS, HEREBY ASSUME ALL OF THE RISKS OF REQUESTING THIS SERVICE, including by way of example and not limitation, any risks that may arise from contracting COVID-19 from my Service Provider, gross negligence, negligence or carelessness on the part of the Service Provider and releasing my Service Provider from any and all liability from any medical condition, viruses, of the Service Provider and contracting such viruses from the Service Provider. This Waiver and Release of Liability covers any negligence or gross negligence in relation to exposing me or my dependents to the COVID-19 virus from Service Provider while visiting my home.


    I am responsible for determining whether I am physically and medically able to allow the Service Provider into my home and provide Services. I am responsible for determining whether a physical or medical examination should be undertaken before I or my dependents participate in the services being provided and I will abide by any determination, limitation, or recommendation that may be issued by my medical or health care provider. Before, during, and after the services, I am solely responsible for determining my and my dependent’s health and physical status and whether I or my dependents can or should discontinue my participation in the services, or take other actions, to protect my own, and my dependents, health or safety. Service Provider assumes no duty to me or my dependents to ensure my physical or medical ability to participate in the services, whether before, during, or after the services.


    I acknowledge that this Waiver and Release of Liability Form will govern my actions and responsibilities at said services, activity or event.
    In consideration of providing services to me and/or my dependents, I hereby take action for myself, dependents, my executors, administrators, heirs, next of kin, successors, and assigns as follows:


    (A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this event, THE FOLLOWING ENTITIES OR PERSONS: Service Provider and its directors, officers, employees, representatives, employee, and agents;


    (B) I INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this service, activity or event, whether caused by the negligence of release or otherwise. Me and my dependent’s participation in the services is voluntary.


    I acknowledge that Service Provider and its directors, officers, employees, representatives, and agents are NOT responsible for the contamination, errors, omissions, acts, or failures to act of any party or entity conducting in providing the services.

    I acknowledge that this activity, event or service may carry with it the potential for death, serious injury, and property loss.
    The accident waiver and release of liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.

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    Legal Guardian Signature
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  • 37
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  • 38
    Upload Diagnostic paperwork, the latest ABA assessment for your child and the front and back of your insurance card here
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    Max. file size: 10.6MB
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