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Client Enrollment Packet

• Client Awareness Form (please complete and submit)
• Client COVID-19 Acknowledgments (please complete and submit)

Dear Parents/Guardians,

Thank you for choosing Exceptional Expectations, L.L.C. (EE Support Services)! As a result of the current pandemic, Exceptional Expectations, L.L.C. (EE Support Services) has implemented protocols and procedures to comply with current CDC guidelines. Thus, we have updated our Client Awareness form to clarify the responsibilities of EE Support Services, Service Providers, and our Clients.

You will receive a copy of this form.

Please review each statement and refer to this document while utilizing support services.

Parent/ Guardian Name *

Email*

I hereby certify that I am the parent and/or legal guardian of:*

Client First Name *

Client Last Name *

Client Awareness

Completion of the Awareness Form and COVID-19 Responsibilities document is required to continue to receive support services.

Please read the following document, check each box and sign acknowledging that you understand and will comply with the items within this document. Both clients and providers are responsible for reviewing and acknowledging awareness to the information below.

Exceptional Expectations, LL.C. (Exceptional Expectations) is an agency contracted with the Arizona Division of Developmental Disabilities (D.D.D.) to provide Home- and Community-Based Services (HCBS) including Respite, Habilitation, Day Treatment Summer and Day Treatment Training services to any child who is eligible for these services.*

Neither Client nor Service Provider is obligated to participate in any situation in which the personal safety or comfort of the individual is compromised. This includes any situation in which factors arise after the initiation of services that cause harm, discomfort, or fear for the individual. Factors include, but are not limited to, personal dynamics such as personal safety, hygiene and/or habits, the behavior of pets, an individual's communication style, and/or the status of the home (e.g. organization, cleanliness, routines). Client acknowledges that it is his/her responsibility to report such concerns to an Agency Director for appropriate actions to be taken.*

Exceptional Expectations, LLC. and its staff are required by law to report immediately any suspicion of abuse, neglect, or exploitation of a Child. Client acknowledges that it is his/her responsibility to report to an Agency Director any concerns regarding the aforementioned situations involving a Service Provider employed by Exceptional Expectations, LLC. Client acknowledges that it is the responsibility of the Agency Director to report such concerns to D.D.D. and that D. D.D. may initiate its own internal investigation into any allegations of abuse, neglect, or exploitation. Client acknowledges that Exceptional Expectations, L.L.C. will diligently and comprehensively review each situation.*

Scheduling

The Client will experience greater daily contact with the Service Provider than will Exceptional Expectations, L.L.C. As such, Client agrees to notify Exceptional Expectations L.LC. of any concerns with any Service Provider employed by Exceptional Expectations, L.L.C., and to cooperate with Exceptional Expectations, L.L.C. in its efforts to evaluate those employees providing services to the child. Efforts may include but are not limited to, semi-annual Quality Assurance surveys, quarterly communication via phone or email, and Random Billing Inquiries.*

Client is allowed to schedule services directly with the Service Provider of Exceptional Expectations, consistent with the number of respite, habilitation, day treatment summer, and day treatment training hours the client has been authorized by D.D.D*

It is the shared responsibility of the Client and Service Provider to inform Exceptional Expectations and one another in advance, when possible, of absences. Please email scheduling@exceptionalexpectations.com*

It is the responsibility of the Client to inform Exceptional Expectations, L.L.C. when a substitute Service Provider will be necessary, for example, when a Service Provider is expecting an extended absence. Exceptional Expectations, LLC. and its staff will diligently attempt to provide a substitute Service Provider; however, circumstances may limit the agency's ability to provide a substitute. Please email scheduling@exceptionalexpectations.com.*

Program Enhancement

The Client should work collaboratively with Exceptional Expectations, LLC. and its staff to enhance the program selected for the child. Client may participate in a phone-conference and complete the necessary Client Input Form in lieu of an in- home meeting. Exceptional Expectations, L.L.C., and its staff acknowledges that ultimately, program decisions regarding the Client reside with the parent or guardian, subject to the rules and regulations of the D.D.D. Program objectives must align with the Child's Individual Support Plan (ISP) and reflect appropriate consideration of the Child's functional abilities.*

Client involvement will enhance the implementation of the Child's home program. The Client should be knowledgeable of the program elements and communicate necessary changes/updates in the Child's programming needs in a timely fashion. Client participation may include but is not limited to, inviting Agency staff to participate in ISP or other planning meetings. Participating in Home Programming meetings to help define appropriate goals, and/or attending pertinent training for techniques and strategies.*

The Child's most current HCBS Pre-Service Orientation Plan must be reviewed by all Service Providers and/or Directors of Exceptional Expectations, LLC. that are involved in providing services to the Child, prior to the initiation of services. The Service Provider(s) must be made aware of where this documentation is maintained at the service site (e.g., in a notebook on the shelf or in a file cabinet).*

It is inappropriate to require the Service Provider to complete duties outside the scope of Home- and Community-Based Services. Such services may include, but are not limited to housework (e.g. vacuuming, cleaning, and laundry), clerical work, or other duties outside the scope of Respite, Habilitation, Day Treatment Summer, and/or Day Treatment Training Services. It is permissible to engage services that are related to a child’s individualized goals for daily living and independent living skills. For example, the Service Provider may assist a child to sort, wash/dry, and fold clothes if such a goal is an identified and documented need for the child. Certain courtesies may be extended by the services provider such as assisting with “toy clean up” at the end of the day and such actions may be requested by the Client and agreed upon by the Service Provider. It is up to the mutual discretion of the Client and Service Provider to arrange for such non- contracted services and such agreement is considered outside the scope, liability, and financial obligation of Exceptional Expectations, L.L.C*

Service Requirements

Service Providers for Exceptional Expectations, LLC. may not provide services for Client on behalf of Exceptional Expectations, LLC. until Exceptional Expectations, LL.C. has received a service authorization from D.D.D. to provide services. It is the responsibility of the Client to request that the Support Coordinator grant the service authorization to Exceptional Expectations, L.L.C*

A Service Provider may not request additional compensation from the Client for providing services to the Client who is eligible and authorized for services by DDD. The Client should inform Exceptional Expectations, LLC. if a Service Provider makes such a request.*

The Client is financially responsible for any unauthorized services performed by a Service Provider of Exceptional Expectations, LLC. and any service hours that exceed the number of hours assigned by DDD are considered a Private Pay Service and will be billed to the Client by Exceptional Expectations, L.L.C. at the Service Provider's rate*

Client shall be available to review, verify, and sign monthly documentation, including Time Logs (AutoVisit) and Habilitation Records (for habilitation services only). It is recommended that the Client and/or Provider maintain copies of submitted Time Sheets. A copy of the Child's Habilitation Record must be maintained at the service site in a safe and inaccessible location from children and pets*

Peer and/or sibling participation in Habilitation Services typically is inappropriate unless the Child's Program provides for such participation. As such, the inclusion of peers and/or siblings during habilitation services should be limited in time and scope and should at no time reduce the Service Provider's ability to provide quality services.*

The inclusion of peers and/or siblings in Respite Services must be approved by a Director of Exceptional Expectations, LLC. The Client is responsible for paying an additional stipend to the Service Provider for caring for siblings. The Client may contact an Agency Director to discuss customary and/or appropriate payment for providing care for sibling(s). The Division of Developmental Disabilities is not responsible or liable for providing services for peers and/or siblings.*

Supplies and Materials

Service Providers for Exceptional Expectations, LLC. cannot be required to purchase/provide materials required for the services to be performed. Client shall provide all materials required for the services to be performed, including those necessary to satisfy necessary special dietary needs, appropriate reinforcement to promote Child's learning (i.e., incentives, rewards, prizes), elective costs/fees associated with the Child's participation in the community (e.g., meals at a restaurant, admission to a museum), or teaching materials*

Exceptional Expectations, LLC. maintains a resource library that contains relevant teaching supplies and instruments available for loan to Service Providers and Clients. It is the Client's responsibility to reimburse Exceptional Expectations, L.LC. a monetary sum equal to the item's replacement value for any item borrowed and subsequently lost, damaged, or ruined.*

Transportation

Service Providers of Exceptional Expectations L.L.C. are responsible for their own transportation to and from the service site (typically the Client's home). Transportation is not within any Service Provider's scope of service with Exceptional Expectations, L.L.C. Transportation of a Client is expressly outside the scope of service provided by Exceptional Expectations, L.LC.*

Client acknowledges that in order for the Client and Service Provider to enter into an agreement in which the Service Provider transports the Child, a signed Transportation Liability Form must be completed by both the Client and Service Provider and approved by a Director of Exceptional Expectations, L.L.C. Transportation and reimbursements under this arrangement remain outside of the scope of services of Exceptional Expectations, LLC. and Exceptional Expectations, LLC. and its Directors accept no liability for this transportation agreement.*

I have read each of the above statements and do hereby state my awareness of this information. It is my intention to enter a relationship with Exceptional Expectations, L.L.C. and I accept the policies and practices of this agency.*

Signature Date*

Month/Day/Year

COVID-19 Responsibilities: Parent/Guardian Acknowledgment

As a result of the current pandemic, EE Support Services have implemented protocols and procedures in the best interest of the health and safety of our clients and staff, their families, and others. The adherence to these protocols is the responsibility of all Exceptional Expectations’ clients.

I acknowledge that it is my responsibility to notify Exceptional Expectations of any health or medical concerns pertaining to household members.*

I acknowledge that if my child displays any of these symptoms, it is the parent/guardian's responsibility to contact Exceptional Expectations.*

I acknowledge that it is my responsibility to report to Exceptional Expectations if my child or anyone who they have come into contact with has been diagnosed with or has symptoms of COVID-19.*

I acknowledge that sanitation procedures such as use of hand sanitizer, hand washing, and the use of sanitizing wipes for supplies and surfaces are highly suggested for in-home visits.*

I acknowledge that I will notify Exceptional Expectations and my in-home service provider of any allergies or sensitivities to any of the above-listed sanitation products, as well as any allergies/sensitivities in relation to personal protective equipment (i.e. latex gloves, face masks, etc.) that my child may come into contact with.*

I acknowledge that Service Providers of Exceptional Expectations are not authorized to administer any medications while providing services without the express written approval of a Director of Exceptional Expectations, L.LC. To the extent that the administration of medication is necessary, it is the responsibility of the Client to provide the Service Provider with adequate instruction.*

If you or anyone in your household has come into more than passing contact with someone (e.g., coworker, friend, extended family, etc.) who has tested positive for Coronavirus please contact the Agency Director Alexxa Roberts or email enrollment@exceptionalexpectations.com immediately to determine next steps.*

Parent or Guardian Signature*

Signature Date 1*

Month/Day/Year