Client Intake · Step 1 of 2

Service Agreement

Please read each section carefully and complete all fields below. Submitting this form serves as your electronic signature and acknowledgment of the terms described.

Client information

Parent / guardian name *

Child's name *

Child's date of birth *

Phone number *

Email address *

Today's date *

Home address *

1. Parties to this agreement

This Service Agreement ("Agreement") is entered into between AJG Behavioral Services, operated by Adam Gonzales, Board Certified Behavior Analyst (BCBA), located in the Central Valley, CA ("Provider"), and the parent or legal guardian identified above ("Client").

2. Description of services

AJG Behavioral Services provides individualized Primary Care Behavioral Pediatrics services rooted in Applied Behavior Analysis (ABA). Services are designed to support families in understanding and addressing challenging behaviors, building new skills, and creating consistent strategies across home and caregiving environments.

Services may include:

Initial behavioral assessment
Development of an individualized behavior plan
In-home parent coaching sessions (60 minutes each), with virtual sessions available at parent request
Progress review and plan adjustments
Written behavior plan and caregiver resources
Brief check-ins via email or text between scheduled sessions

All sessions are conducted in-home. Coaching sessions may be conducted virtually at parent request.

3. Session package

Please select the service package that best fits your family:

4-Week package — Focused supportFree 10–15 min consultation + 4 sessions (assessment, 2 coaching, progress review). Best for one primary concern.

6-Week package — Comprehensive supportFree 10–15 min consultation + 6 sessions (assessment, 4 coaching, final review + summary report). Best for multiple or complex concerns.

4. Fees and payment

Service fees are discussed during the free consultation call. Payment is due prior to or at the time of each session unless a payment plan has been agreed upon in writing. AJG Behavioral Services does not currently bill insurance. A paid receipt can be provided upon request for HSA/FSA or insurance superbill purposes.

5. Cancellation and late policy

The Provider understands that life with children is unpredictable. The following policy helps protect everyone's time:

24+ hours notice: No charge.
Less than 24 hours notice: A late-cancellation fee may be charged.
No-show (missed session without notice): Full session fee may be charged.
The Provider reserves the right to waive fees at their discretion in cases of emergency or illness.

Repeated cancellations or no-shows may result in termination of services at the Provider's discretion.

6. Confidentiality and HIPAA

All information shared during sessions is kept confidential in accordance with HIPAA and applicable California law. Information may be disclosed without consent only when: required by law or court order; there is reasonable belief of risk of harm to the child or others; mandated reporting of suspected abuse or neglect is required; or with written consent of the Client. A separate Notice of Privacy Practices will be provided and must be acknowledged at intake.

7. Scope and limitations of services

Parent coaching provided by AJG Behavioral Services is not psychotherapy, mental health treatment, or medical care. Adam Gonzales, BCBA does not diagnose medical or psychiatric conditions. If additional services are indicated, the Provider will discuss a referral.

8. Role in custody disputes

AJG Behavioral Services will not serve as an advocate in custody disputes, provide written recommendations favoring one parent, or selectively disclose records. Services may be paused if active legal proceedings compromise the therapeutic relationship. Records may be subject to subpoena. Please inform the Provider early if custody proceedings are involved.

9. Understanding extinction bursts

As part of informed consent, clients must understand extinction bursts — a temporary increase in a challenging behavior when a previously reinforced behavior stops working. This is a natural, predictable part of behavior change, not a sign the strategy is failing.

What is an extinction burst?

When a behavior that used to "work" for a child is no longer reinforced, the child will often initially respond by doing more of that behavior — or doing it more intensely — before it decreases. Examples: a child who got screen time by crying may cry louder at first; a child who avoided toothbrushing by tantruming may escalate before accepting the new routine; new behaviors like hitting or flopping may briefly appear.

Consistency is critical. If caregivers give in even once during an extinction burst, the behavior can become stronger and more persistent. The Provider will prepare you in advance and support you through this phase. Do not abandon the plan without first consulting the Provider.

10. Termination of services

Either party may terminate this Agreement at any time with written notice (email is acceptable). The Client is responsible for payment of any sessions completed prior to termination. The Provider may terminate services if the Client is non-compliant, becomes abusive or threatening, or repeated cancellations prevent meaningful service delivery.

11. Consent and acknowledgment

By submitting this form, I confirm that I:

Am the parent or legal guardian of the child identified in this agreement

Have read and understand this Agreement

Consent to the services described herein

Have received (or will receive) the AJG Behavioral Services Notice of Privacy Practices

Agree to the cancellation and payment policies outlined above

Have been informed about extinction bursts and understand that a temporary increase in challenging behavior is an expected part of the treatment process

Understand the boundaries of AJG Behavioral Services in any custody or legal proceedings

Client signature (type full legal name) *

Date *

Printed name *

Relationship to child *

Adam Gonzales, BCBA (Provider) — Provider signature will be completed upon receipt.

Questions? adamg@ajgbehavioral.com · (559) 622-4408