ABA Assessment and Treatment Plan

This report is confidential and for professional use only. The content may not be divulged to any person
or agency without consent of the parent, legal guardian, or patient, as appropriate. Fax to Regence
BlueShield 1-888-496-1540 or by mail to: Regence BlueShield PO Box 1271 MS E9H, Portland, OR 97207-
1271
Patient Name: Treatment Agency Name:

Patient Birth Date: Lead Behavior Therapist Name:

UMP ID Number (Include Alpha Characters): Therapist Assistant Name(s):

RECOMMENDED TREATMENT HOURS/SESSIONS

Direct Patient Support - hours Caregiver/Parent Training - 1 session per

(weekly) day
(monthly)
Recommended e.g., 10 hours in home
Hours and Setting 2 hours in community
(indicate # of
Sessions for
Caregiver/Parent
Training)

Program Supervision - ABA treatment day program in a clinic or

includes observation of the treatment being outpatient hospital setting
delivered, observation of the child in his/her
natural setting, and communication with (weekly)
BCBAs/Techs delivering ABA services.
(weekly)
Recommended e.g., 10 hours in home
Hours and Setting 2 hours in community

Rationale for this treatment plan should be reflected in the body of the report below, as well as the
severity ratings on the Applied Behavior Analysis Authorization Request Form submitted with this
treatment plan.

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BACKGROUND AND HISTORY Indicate at least the following or indicate NA.

Past psychiatric history:

For diagnosis of autism spectrum disorder, include date of diagnosis and diagnosing provider name. Also
include initial diagnosis documentation and comorbid diagnoses if this is an initial preauthorization
request.

Chief Complaint and History of Present Illness (HPI): Include all core deficit areas of autism, challenging
behaviors, adaptive, motor, vocational, and cognitive skills, and any other related relevant areas. In
addition to addressing the chief complaint, one should be able to understand the patient’s level of
functioning by reading this section. Please provide a detailed summary of information below for both
Preauthorization and Concurrent review requests.

Social Communication: includes persistent deficits in social communication and social

interaction, as outlined in DSM-5

Behavior: includes restricted interests and repetitive behaviors, as well as related challenging
behaviors (e.g., tantrums, aggression, etc.)

Adaptive skills:

Motor:

Vocational:

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 Cognitive:

Family history: Focus on relevant family psychiatric history and related family training in support of
performing ABA therapy

Social history: Information about where the patient lives, with whom, as well as any other relevant
information about social context or stressors.

Medical history:

Active medical problems:

Current medical providers:

Current medications, dose, purpose, and potential major side effects:

Allergies, special diets, etc.:

Past medical problems:

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Educational History: Summarize past and current educational plan, including what services are being
provided in the educational setting. Discuss whether functional behavior assessments, behavior plans,
and/or aversive plans have been used in the school setting. State where the information was obtained
(e.g., review of records, interview, etc.).

History:

Current:

Past and Current Services: Outline all additional services being provided outside school through any
other agency or funding source. Include frequency, provider, and funding source.

Ensure there is not redundancy with recommended ABA treatment plan.

Outline previous courses of ABA therapy; including dates, setting, and the outcome.

ASSESSMENTS COMPLETED FOR EVALUATION

Measures used: Discuss all sources of information used in evaluating the patient, including standardized
(norm-referenced) and curriculum-based measures, interviews (e.g., parent, caregivers, teacher), direct
observation at home/school/community, etc. Please complete the Applied Behavior Analysis
Authorization Form and attach to this treatment plan.

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Evaluation Findings: Briefly summarize findings, including test scores if available. Summary can be brief;
a couple sentences per measure. E.g., Vineland-II results demonstrated delays in communication and
socialization are present. Tables and score reports can be used if easier to present information. Present in
appendices if desired. Briefly summarize findings derived from observations in natural settings (e.g.,
home, school).

Functional behavior assessment/analysis findings: Functional assessment or analysis results should be

included here. The following components should be included:

1) Operational definition of behavior

2) Hypotheses or analysis about functions supported by indirect and direct assessment results

3) Functional assessment or analysis data to support function hypotheses or analyses

4) Baseline data, including frequency, duration, and intensity data, as appropriate to behavior.

Include assessment of risk (e.g., due to elopement or other unsafe behavior) as appropriate.

Goal domains derived from assessment: Include statement about how the information obtained
supports goals in specific areas. E.g., Assessment information suggests CHILD needs treatment goals in
the areas of Social Communication, Behavior, Adaptive skills, Motor skills, Vocational skills, and Cognitive
skills.

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TREATMENT PLAN IMPLEMENTATION

Treatment Plan: This section should include a brief overview of the treatment plan, including:

1) How ABA will be applied to the patient (e.g., ABA as applied to CHILD will include home and
community based 1-1 intervention for (x) hours per week to target social, communication, and
adaptive goals)

2) Whether a positive behavior support plan is required to address challenging behaviors

3) The parent/caregiver training plan

4) How the treatment plan will be coordinated with other providers, including school (e.g., speech
pathologist, medical providers, outpatient psychologist, teachers, etc.).

Goals and objectives can be found in Appendices A, B and C of this report.

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Maintenance/Generalization/Discharge Plan: This section should include a statement about how
maintenance and generalization will be addressed, how services will be reduced or transitioned to the
parents and/or how the patient will be transitioned into other less intensive services (e.g., school,
outpatient, etc.). This should be more specific as the patient progresses in therapy. The transition or
discharge plan should be specific, data driven, and include criterion for discharge.

Goals and objectives can be found in Appendix D of this report.

ABA Agency or ABA Service Coordinator: _______________________________________________

__________________________________ __________________________________

Print Name of Lead Behavior Therapist Signature of Lead Behavior Therapist

__________________________________ __________________________________

Print Name of Therapist Assistant Signature of Therapist Assistant

__________________________________ __________________________________

Print Name of Therapist Assistant Signature of Therapist Assistant

__________________________________ __________________________________

Print Name of parent/caregiver Signature of parent/caregiver

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 Appendix A: Goals and Objectives for Skill Acquisition

Include goals and objectives in all relevant areas. Goals should be worded in such a way that they can be
measured to track progress. Objectives should be clear steps toward a goal. Goals and objectives should
be worded in such a way that they are easily interpretable to readers who are not familiar with
behavioral terminology (i.e., parents, case managers, etc). The specified domains were decided upon by
the HCA and include social communication, behavior (restricted interests, repetitive behaviors, other
challenging behaviors), adaptive, motor, vocational, and cognitive. Broadly defined, all relevant goals
(e.g., play skills, self-help, etc.) should fit into one of these categories. Goals for reduction of problem
behavior should be outlined in Appendix B: Positive Behavior Support Plan.

Skill Acquisition Goals: All skill acquisition goals and their corresponding objectives should be outlined
here. Goals should be organized by skill area (e.g., social communication), should be titled with a short 2-
3 word title, should include a broad goal that demonstrates the expected outcome, and then be broken
down into specific objectives(also titled) that clearly outline target skills to be taught (e.g., within
communication, expressive labels and requesting might be two specific objectives). Objectives should be
measurable and measurement strategies, including mastery criteria, should be clearly stated (e.g.,
mastery criteria are met when a correct response occurs on 9 out of 10 opportunities across three
sessions). Goals should be written in a manner that is consistent with how the therapists are taking data
so data can easily be reported back for utilization review of progress. If progress will be documented by
using a formal assessment tool (e.g., a measure associated with a curriculum), this should be stated in
how the goal is written (e.g., patient will show improvement according to the ____ assessment).

If the patient is receiving ABA therapy services primarily to address reduction of challenging behaviors,
this section may be marked NA and the Positive Behavior Support Plan should be outlined in Appendix B.

DOMAIN: Social Communication

Goal 1:

Baseline:
Treatment Approaches to be Used:
Progress:
Objective 1A

Baseline:
Progress:

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Goal 2:

Baseline:
Treatment Approaches to be Used:
Progress:
Objective 2A

Baseline:
Progress:

DOMAIN: Adaptive

Goal 1:

Baseline:
Treatment Approaches to be Used:
Progress:
Objective 1A

Baseline:
Progress:

Goal 2:

Baseline:
Treatment Approaches to be Used:
Progress:
Objective 2A

Baseline:
Progress:

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DOMAIN: Motor

Goal 1:

Baseline:
Treatment Approaches to be Used:
Progress:
Objective 1A

Baseline:
Progress:

Goal 2:

Baseline:
Treatment Approaches to be Used:
Progress:
Objective 2A

Baseline:
Progress:

DOMAIN: Vocational

Goal 1:

Baseline:
Treatment Approaches to be Used:
Progress:
Objective 1A

Baseline:
Progress:

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Goal 2:

Baseline:
Treatment Approaches to be Used:
Progress:
Objective 2A

Baseline:
Progress:

DOMAIN: Cognitive

Goal 1:

Baseline:
Treatment Approaches to be Used:
Progress:
Objective 1A

Baseline:
Progress:

Goal 2:

Baseline:
Treatment Approaches to be Used:
Progress:
Objective 2A

Baseline:
Progress:

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 Appendix B: Positive Behavior Support Plan

Positive Behavior Support (PBS) Plan for Reducing Challenging Behaviors: Should follow from functional
assessment/analysis results discussed above and include, 1)operational definitions of behaviors, 2) a
brief statement of identified functions of behavior, 3) suggested parent/caregiver/staff response to
behaviors when they occur, 4) recommended antecedent interventions to prevent behaviors, 5) plan for
teaching replacement behaviors with clear goals, 6) statement about how the proposed interventions
were derived from the functional assessment/analysis, 7) plan for coordinating PBS Plan across settings.

If the patient has minimal challenging behaviors and the primary focus of their ABA treatment plan is on
skill acquisition, this section may be marked NA and the skill acquisition goals should be outlined in
Appendix A.

DOMAIN: Behavior

Goal 1:

Baseline:
Treatment Approaches to be Used:
Progress:
Objective 1A

Baseline:
Progress:

Goal 2:

Baseline:
Treatment Approaches to be Used:
Progress:
Objective 2A

Baseline:
Progress:

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Appendix C: Parent/Caregiver Training Goals

This section should address caregiver goals for skill acquisition (e.g., parents will learn to implement the
PBS Plan). It should include clear goals and objectives, written in the same format as the patient’s skill
acquisition goals.

All children should have parent/caregiver training goals in their treatment plan, regardless of the nature
of the child’s goals/objectives. If the treatment plan is for an adult or an individual living in a group
setting, this portion of the plan should focus on training caregivers. This section may not be marked NA.

Goal 1:

Baseline:
Treatment Approaches to be Used:
Progress:
Objective 1A

Baseline:
Progress:

Goal 2:

Baseline:
Treatment Approaches to be Used:
Progress:
Objective 2A

Baseline:
Progress:

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 Appendix D: Maintenance/Generalization/Discharge Plan

This section should include a statement about how maintenance and generalization will be addressed,
how services will be faded and/or how the patient will be transitioned into other less intensive services
(e.g., school, outpatient, etc.). This should be more specific as the patient progresses in therapy. The
fading plan should be specific, data driven, and include criterion for discharge.

Statement about how maintenance and generalization will be addressed, etc.

DOMAIN: Social Communication

Goal 1:

Criterion for Discharge:

Referral Program:
Objective 1A

Criterion for Discharge:

Referral Program:

Goal 2:

Criterion for Discharge:

Referral Program:
Objective 2A

Criterion for Discharge:

Referral Program:

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DOMAIN: Adaptive

Goal 1:

Criterion for Discharge:

Referral Program:
Objective 1A

Criterion for Discharge:

Referral Program:

Goal 2:

Criterion for Discharge:

Referral Program:
Objective 2A

Criterion for Discharge:

Referral Program:

DOMAIN: Motor

Goal 1:

Criterion for Discharge:

Referral Program:
Objective 1A

Criterion for Discharge:

Referral Program:

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Goal 2:

Criterion for Discharge:

Referral Program:
Objective 2A

Criterion for Discharge:

Referral Program:

DOMAIN: Vocational

Goal 1:

Criterion for Discharge:

Referral Program:
Objective 1A

Criterion for Discharge:

Referral Program:

Goal 2:

Criterion for Discharge:

Referral Program:
Objective 2A

Criterion for Discharge:

Referral Program:

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DOMAIN: Cognitive

Goal 1:

Criterion for Discharge:

Referral Program:
Objective 1A

Criterion for Discharge:

Referral Program:

Goal 2:

Criterion for Discharge:

Referral Program:
Objective 2A

Criterion for Discharge:

Referral Program:

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