TRICARE OVERSEAS PROGRAM (TOP) Applied Behavior Analysis (ABA) Assessment Form

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1 The is a brief record of the major aspects of the ABA Treatment Plan required. This is not a complete patient history or comprehensive record of other intended therapies. Section 1: Patient Information Date: Patient Name: Patient DOB: Age: Patient DoD Benefits Number (DBN): Referring Provider Name: Referring Provider Contact Number: Section 2: Brief Background Information and History Patient s condition: Patient s diagnosis: (Autism Spectrum Disorder, Autistic Disorder, Asperger s Disorder, or Pervasive Developmental Disorder): Medical co-morbidities: Family history: Is the patient enrolled in a school? If yes, please indicate the number of weekly hours enrolled

2 Is the patient receiving other support services (i.e. Occupational Therapy, Physical Therapy and Speech and Language Pathology)? If yes, please list the support service and indicate the number of hours per month for each service: Has the patient had any previous ABA therapy? If yes, please indicate the duration of previous ABA therapy (number of hours per calendar month): Review of recent assessments/reports (file review): Any recent functional behavior assessment, cognitive testing and/or progress reports?

3 Section 3: Initial Assessment Date of initial assessment (DD/MM/YYYY) Duration of the initial assessment (appointment duration in hours): to Recommendation of the number of monthly hours for ABA interventions: Is the patient able to actively participate in the ABA therapy? If no, please provide reasons why patient is unable to participate: Identify objectively measured behavioral deficits that impede the patients safe, healthy, and independent functioning in all domains (i.e. social, communication, and adaptive skills): Clearly define measurable targeted behaviors in all domains and objectives and goals individualized to the strengths, needs and preferences of the beneficiary and his/her family members:

4 Section 4: ABA Initial Assessment Recommendations: Proposed Goals and Objectives* Please include specified treatment interventions for each identified target in a functional domain, as identified in the initial assessment. *Each goal and objective must include: Current level (baseline) Behavior parent/caregiver is expected to demonstrate, including condition under which it must be demonstrated and mastery criteria (the objective or goal) Date of introduction Estimated date of mastery Specific plan for generalization Report goal as met, not met, modified (include explanation) Immediate Goals/Objectives (within 6 months of initial assessment): Short Term Goals/Objectives(within 1 year of initial assessment): Long Term Goals/Objectives (within 2 years of initial assessment):

5 Level of support by parent/caregiver required for patient to demonstrate progress towards short and long term goals: Section 5: Reassessment Period covered by this assessment (MM/YY) through to (MM/YY) 6 months 12 months 18 months 24 months At any point since the initial ASD diagnosis, has the patient undergone an Autism Diagnostic Observation Schedule, Second Edition (ADOS-2)? If yes, please provide date of evaluation: Total number of hours of ABA services received from BCBA/BCBA-D for indicated period above: Patient s Response to Treatment: Initial Assessment Score: Current Assessment Score: Please provide a brief description of the response to specific treatments and the outcomes:

6 Were there any ineffective interventions? If yes, please include details on which interventions were ineffective and why: Patient Degree of Progress Towards Long and Short Term Treatment Goals: (List specific and measurable goals and objectives that appear on the initial assessment and give status of each progress made, date of mastery, level of parent/caregiver support required) Goal/Objective: Progress towards achieving goals/objectives for this period: Level of support required by parent(s)/caregiver(s) to demonstrate progress towards the goals and/or reason or lack/inability for parental/caregiver involvement: Date of mastery (when applicable): *Please print extra pages if necessary

7 Revisions to Initial Treatment Plan Assessment New behaviors and the targets for these: New goals and objectives (please list) Number of recommended monthly hours of ABA therapy needed: Projected duration of the ABA treatment (additional hours that would be needed) Section 6: Parent/Caregiver Training Please include level of parent/caregiver involvement and/or reasons for lack/inability for parental/caregiver involvement. Is parent/caregiver training possible? If, please indicate why not:

8 Specify parent/caregiver training procedures - protocols shall be selected jointly by the BCBA/BCBA-D and the parent(s)/caregiver(s): Please describe data collection procedures, used by parent/caregivers: Goals/objectives for parent/caregiver training on implementation of selected treatment protocols with the patient at home and in other settings:

9 Section 7: Transition / Discharge Plan The desired outcomes for discharge should be specified at the initiation of services and always refined throughout the treatment process. This should include a written plan that specifies details of monitoring and follow-up as is appropriate to the patient and parents/caregivers. Please list desired outcomes that need to be achieved before discharge or transition (discharge criteria): Does the patient still qualify for / benefit from ABA treatment? If, what is/will be the discharge date: Reasons for patient transition/discharge out of ABA Program: The patient has met ABA goals and is no longer in need of ABA. The patient has made no measurable progress toward meeting goals identified on the ABA Initial Assessment ABA Treatment plan gains are not generalizable or durable over time and in spite of best effort and treatment plan modifications do not transfer to social settings outside of the family. The patient can no longer participate in ABA (due to medical problems, family problems, or other factors that prohibit participation). The family is interested in discontinuing services. Please return this ABA to the referring US Military Treatment Facility (MTF), the contact details can be found on the TRICARE Authorization Letter, with a copy to TOP Regional Call Cente. Attn: ABA Review Team Fax: Name of BCAB/BCBA-D: Signature of treating BCAB/BCBA-D: Date:

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