APPLIED BEHAVIOR ANALYSIS THERAPY

Individualized Treatment Plan – Progress Report

Submitted date: Fax Affiliate link

Patient Name: DOB: Kaiser Permanente Member Number:

Patient Address: Age: Male: Female:

Caregivers: Phone number: Email:

Primary Diagnosis: Comorbidities: Medications:

Diagnosing Provider: Date of first diagnosis: Current PCP:

ABA agency: BCBA: (name & BACB RBT/CBT team:

number)

Report date: Current authorization dates: Requested Authorization Dates:

Home based: Center based: Telehealth: Comprehensive Focused

Caregiver-Lead: Other:
BCBA contact: (email & phone number) Administrative contact: (email & phone
number)
ABA session schedule:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday & Sunday
APPLIED BEHAVIOR ANALYSIS THERAPY
Individual Treatment Plan – Progress Report
Client Name:
Report Date:

Current Services
Education Teacher’s name Schedule
(school name) (Type of Classroom)

IEP: 504: In person:

Other: Virtual:

SLP (facility name) Therapist name:

OT (facility name) Therapist name:
Other: (facility name) Therapist name:
Past ABA services (facility name) (dates of service) Reason for termination

Coordination of Care
Date Service Items discussed

SERVICE DELIVERY

Client/facility attendance in the completed treatment period:

Cultural and/or environmental considerations relevant for treatment planning:

Issues related to service delivery, if any:

Note any barriers for fulfilling all approved clinical hours (i.e., The Disney Clinic was
closed over the months of January to March due to COVID-19 pandemic, The Mouse
family took a 3-week vacation in May, there was a clinical team transition which left
Mickey with no ABA services for 2 weeks, etc.)

REASSESSMENT & UPDATE REPORT

Re-assessment Results
(Update and summary: current living situation, updates to medical condition and/or medications, cultural
and environmental changes to be taken into considerations for treatment planning)
APPLIED BEHAVIOR ANALYSIS THERAPY
Individualized Treatment Plan – Progress Report
Client Name:
Report Date:

Examples: parents separated, new sibling or more family living at home with Mikey, etc.

Developmental/Norm based assessment:

ASSESSMENT RESULTS
Indirect – Norm reference assessment & results (note these are required annually)
Assessment tool Date completed Evaluator (s)
Vineland:
ABAS
:
(other)

(insert assessment results tables)

(Assessment name)
Assessment Update (date) Update (date) Update (date) Update (date)
scores

(insert assessment results tables from current and prior assessments)

Direct/Curriculum based assessment & results

Assessment tool Date completed Evaluator (s)
VB MAPP:
EFLs:
PEAK:
AIM:

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APPLIED BEHAVIOR ANALYSIS THERAPY
Individualized Treatment Plan – Progress Report
Client Name:
Report Date:

AFLS:
ABBLS:
Carolina Curriculum:
SSRS:
Socially Savvy:
__________________:
(other)

(insert assessment results tables)

GOALS UPDATE
Targeted Goals Goals in Progress Goals Met Goals Goals in
Discontinued regression
Program goals:  Mands -carrier  Mands – one
phrase word
 Toilet training  Toilet training -
- BM urination
 Washing hands
 Parallel play

Behavior goals:  Waiting  Coping skills

Caregiver goals:  Using a visual  Collecting ABC

schedule data
#total:

CUMULATIVE MATERED GOALS:

(cumulative bar graph of mastered goals)

PROGRAM GOALS
Receptive Communication:
1. Lesson Name & goal
Baseline:
Date introduced:
Estimated Mastery date:

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APPLIED BEHAVIOR ANALYSIS THERAPY
Individualized Treatment Plan – Progress Report
Client Name:
Report Date:

Teaching modality/data:
Mastery criteria:
Generation & Maintenance criteria:
2. (EXAMPLE)Following safety instructions - Mikey Mouse will follow 5 safely instructions across 90% of
opportunities. (IN PROGRESS)
Baseline: 2/1/21; Mikey was observed to follow 1 out of 5 instructions (“come here”) with 30% independence during a
2 hours home assessment visit.
Date introduced: 1/7/21.
Estimated Mastery date: 5 months
Teaching modality/data: Natural Environment Teaching
Mastery criteria: Across 3 people (1 caregiver) and 3 environments with 90% independence.
Progress information: Mikey follows 3 safety instructions (stop, come here, sit down) with 90% independence. He is
currently 40% independent with following “stand up” and “my turn” across sessions.
Generation & Maintenance criteria: Safety instructions will be embedded into Mikey’s ABA sessions by capturing and
contriving teaching opportunities with ABA team and caregivers. Upon mastery following safety instructions will be
maintained with family across daily routines.

Expressive Communication Goals:

Socialization Goals:
Self Help and Daily Living Skills Goals:
Pragmatic Skills:
Behavior Goals:

Indirect assessment & conditional probably results

Assessment tool Date completed Evaluator (s)
QABP:
MAS:
FAST:
:
(other)

Behavior Intervention Plan

Maladaptive behaviors – (operational definition, rate, intensity, etc.)
Coping skills
Replacement skills
(include entire BIP used to implement in field)

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APPLIED BEHAVIOR ANALYSIS THERAPY
Individualized Treatment Plan – Progress Report
Client Name:
Report Date:

Behaviors Baseline Update Update Update

(Initial 2/1/2021
date:9/1/21)
SIB: Head banging 20 occurrences 10 occurrences
per session hour per session hour

Crisis plan
CAREGIVER PARTICIPATION IN PROGRAM
Compliance with treatment recommendations and active caregiver/parent participation are imperative
for service to continue. Treatment is designed to be meaningful and sustainable by empowering
caregiver(s)/parent(s) to generalize and maintain skills in their daily lives.
Plan for Family Participation
Attendance in meetings: (# of meetings completed/ # of meetings scheduled) = %
Participation during sessions: (goals generalized and maintained by family)
Sustaining Interventions outside of ABA sessions:
Other:

Caregiver Education:
1. Lesson Name & goal
Baseline:
Date introduced:
Estimated Mastery date:
Teaching modality/data:
Mastery criteria:
Generation & Maintenance criteria:
1. Meeting Attendance - Mr. Mouse will attend 4 monthly caregiver training meetings with the BCBA across the 6-month
term. (MET) (example)
Baseline: 2/1/21; Mr. Mikey is the main caregiver for his son, he has not received ABA services in the past. was
Date introduced: Upon the start of ABA services.
Teaching modality/data: Caregiver training materials will come from the RUBI curriculum/permanent product.
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APPLIED BEHAVIOR ANALYSIS THERAPY
Individualized Treatment Plan – Progress Report
Client Name:
Report Date:

Mastery criteria: 4 meetings per month across a 6-month term.

Progress information: Mr. Mouse attended 4 monthly parent training sessions over the last 6 months of services.
Topics discussed and trainings included behavior functions, ABC data, TA data for washing hands, Steps to
independence (chapters 4, 5.6.8).
Generation & Maintenance criteria: Training materials will be applied to Mikey’s daily routines as well as
completion of other assignment based on the RUBI curriculum.

PLAN FOR GENERALIZATION OF SKILLS:

PLAN FOR MAINTENCE OF SKILLS:

SUMMARY OF PROGRESS IN THIS REPORT PERIOD

Client progress

Behavioral and adaptive strengths and concerns

Family participation and family adherence to family participation plan and program
requirements

Barriers to progress or provision of services

RECOMENDATIONS
Summary
Strengths

Adaptive and Behavioral Concerns

TRANSITION PLAN:

DISCHARGE CRITERIA:
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APPLIED BEHAVIOR ANALYSIS THERAPY
Individualized Treatment Plan – Progress Report
Client Name:
Report Date:

General

Individualized

Number of requested hours of service per month

AUTHORIZATION DATES
CPT code Hours Description
Behavior Identification Assessment, administered by QHP, each 15
minutes of QHP’s time face-to-face with patient and/or
guardian(s)/caregivers(s) administering assessments and discussing
97151 /auth (U/6M)
findings and recommendations, and non-face-to-face analyzing past data,
scoring/interpreting the assessment, and preparing the report/treatment
plan
Behavior Identification Supporting Assessment, administered by one
97152 /auth (U/6M) technician under the direction of QHP, face-to-face with the patient, each
15 minutes
97153 /mo (U/6M) Adaptive Behavior Treatment by Protocol, administered by technician
under the direction of a QHP, face-to-face with one patient, each 15
97153 w/HO
/mo (U/6M) minutes
modifier
Group Adaptive Behavior Treatment by Protocol, administered by
97154 /mo (U/6M) technician under direction of QHP, face-to-face with 2+ patients, each 15
minutes
/mo (U/6M) Adaptive Behavior Treatment with Protocol Modification, administered
97155 (supervision) by QHP, which may include simultaneous direction of technician, face-
/mo (U/6M) to-face with one patient, each 15 minutes
(program modification)
/mo (U/6M)
(caregiver training)
Family Adaptive Behavior Treatment Guidance, administered by QHP
97156 /auth (U/6M)
(with or without patient present), face-to-face with
(meetings with parents
guardian(s)/caregiver(s), each 15 minutes
and other service
providers)
Multiple-Family Group Adaptive Behavior Treatment Guidance,
97157 /mo (U/6M) administered by QHP (without the patient present), face-to-face with
multiple sets of guardians/caregivers, each 15 minutes

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APPLIED BEHAVIOR ANALYSIS THERAPY
Individualized Treatment Plan – Progress Report
Client Name:
Report Date:

Group Adaptive Behavior Treatment with Protocol Modification,

97158 /mo (U/6M) administered by QHP face-to-face with multiple patients, each 15
minutes
Total

Total number of hours requested for authorization term:

Clinical justifications for a higher/low/modified number of hours:

BCBA signature and date:

Clinical director/Supervising Clinician signature and date:

Parent signature and date: (date it was reviewed with the family)

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