Consultants for Children, Inc.
Name:
Date of Birth:
Member Id:
Funding Source:
Case Manager:
Date of Report:
BACKGROUND AND HISTORY
Child is…..
VINELAND-II Adaptive Behavior Scales Score Summary- Parent/Child Interview
Subdomain/
Domain
Receptive
Expressive
Written
Communication
Personal
Domestic
Community
Daily Living
Skills
Interpersonal
Relationships
Play and
Leisure Time
Coping Skills
Socialization
Raw
Score
SUBDOMAIN and DOMAIN SCORES
Domain
90%
v-Scale
Standard
Conf.
%ile
Score
Score
Interval
Rank
Adaptive
Level
Age
Equivalent
Stanine
Sum:
Sum:
Sum:
www.consultantsforchildren.com
265 South Harlan Street Lakewood, CO 80226 (720) 272-1289 Fax (888) 300-3081
Colorado Springs, Gunnison, Pueblo, Fort Collins, Steamboat Springs, Cheyenne WY, Kansas City MO
Strengths & Weaknesses
Score
S(trength)
Minus
Or
Median
W(eakness)
Gross
Fine
Motor Skills
Sum:
Sum of Domain Standard Scores=
Adaptive Behavior Composite:
Raw
Score
Standard
Score
v-Scale
Score
90% Conf.
Interval
90% Conf.
Interval
%ile
Ranking
Adaptive Level
Stanine
Level
Maladaptive
Behavior Index
Internalizing
Externalizing
Maladaptive Behavior Critical Items:
 Is obsessed with object or activities (for example, constantly repeats words or phrases, is preoccupied with mechanical objects, etc).
o Usually- Moderate Severity
 Displays behaviors that cause injury to self (for example, bangs head, hits or bites self, tears at skin, etc).
o Usually- Moderate Severity
 Destroys own or another ‘s possessions on purpose
o Sometimes- Moderate Severity
 Is unusually fearful or ordinary sounds, objects or situations
o Sometimes- Moderate Severity
 Remembers odd information in detail years later
o Usually- Severe Severity
 Is unable to complete a normal school or work day because of psychological symptoms
o Sometimes- Moderate Severity
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VINELAND-II Expanded Interview Form Pairwise Comparisons
Domain Comparison
Standard
Score
<, >,
=
Standard
Score
Communication
Communication
Daily Living Skills
Communication
Socialization
Daily Living Skills
Subdomain Comparisons
Communication
Receptive
Receptive
Expressive
Daily Living Skills
Personal
Personal
Domestic
Socialization
Interpersonal Relationships
Interpersonal Relationships
Play and Leisure Time
Motor Skills
Gross
Selected Across-Domain
Subdomain Comparisons
Expressive
Expressive
Standard
Score
Difference
Statistical
Significance
Level- .01%
Frequency of
Difference
v-Scale
Score
Difference
Statistical
Significance
Level- .01%
Frequency of
Difference
Daily Living Skills
Socialization
Socialization
Motor Skills
Motor Skills
Motor Skills
v-Scale
Score
<, >,
=
v-Scale
Score
Expressive
Written
Written
Domestic
Community
Community
Play and Leisure Time
Coping Skills
Coping Skills
Fine
v-Scale
Score
<, >,
=
v-Scale
Score
Difference
v-Scale
Score
Interpersonal Relationships
Coping Skills
3
Statistical
Significance
Level- .01%
Frequency of
Difference
Fine
Fine
Fine
Written
Domestic
Personal
TREATMENT GOALS
Specific Goal
Previous Level of Ability: 01/01/2014
Description
Goals: 02/01/2014
Child will…….
1. Goal. Projected Mastery: 02/28/13
Baseline Levels
1. 0%
2. 0%
3. 0%
Specific Goal
Previous Level of Ability: 01/01/2014
Description
2. Goal. Projected Mastery: 11/30/1
3. Goal. Projected Mastery: 02/28/13
Goals: 02/01/2014
Child will…….
1. Goal. Projected Mastery: 02/28/13
Baseline Levels
1. 0%
2. 0%
3. 0%
Specific Goal
Previous Level of Ability: 01/01/2014
2. Goal. Projected Mastery: 11/30/1
3. Goal. Projected Mastery: 02/28/13
Goals: 02/01/2014
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Description
Child will…….
1. Goal. Projected Mastery: 02/28/13
Baseline Levels
1. 0%
2. 0%
3. 0%
2. Goal. Projected Mastery: 11/30/1
3. Goal. Projected Mastery: 02/28/13
Or you can use this format for goals….
GOAL 1: Child will do something good.
Objective 1: Child will do it well for at least 50% of the occurrences.
Baseline Performance =
Introduction Date:
Proposed Mastery Date:
Objective 2: Child will do it well for at least 50% of the occurrences.
Baseline Performance =
Introduction Date:
Proposed Mastery Date:
Objective 2: Child will do it well for at least 50% of the occurrences.
Baseline Performance =
Introduction Date:
Proposed Mastery Date:
BEHAVIOR INTERVENTION PLAN
This is where you put in a behavior intervention plan…at least a preliminary one!
CRISIS RESOLUTION
Steps for Crisis Resolution:
1. Identify potentially frustrating situations. Determine if setting events may be affecting behavior (i.e. fatigue, medication change,
heat, etc.)
2. Ensure that demands have been communicated clearly, sufficient processing time has been given, and that demands are appropriate to
observed frustration levels.
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3. In the event of unsafe behaviors, encourage the child to take space in a quiet area and refrain from social interactions until safe behaviors are
observed.
4. If the child is unable to be redirected to take space, caregivers should ensure that the environment is free from obstructions and that he/she is
on a soft surface to prevent injury. The child should be redirected to the safe space if he/she attempts to leave until he/she is able to follow
simple instructions (i.e. sit down) and demonstrate safe hands and feet.
Caregivers may also call:
Lead Name + Phone number (if you want)
Consultants for Children, Inc. Main office 720-272-1289
Emergency Responders at 911
EMERGENCY DISASTER PLANNING
In case of an emergency situation, Child’s emergency contacts are: (Parent’s Name) Phone number, (Other Parent’s Name) Phone number, (Emergency
contact from intake) Phone number. Child’s parents have listed (Hospital Name) as their hospital of choice in an emergency. The emergency exits for
Child’s house are located: here, here and here. The family has picked (location) as their family meet up location in case of an emergency. (List any other
details relating to Emergency Disaster Planning).
COORDINATION OF CARE
Child’s therapists will share relevant information with his/her school teachers through phone consultation, classroom observation, and/or reviewing
treatment goals via email. Lead Therapist,( name + credentials), will consult on an as need basis and will provide supervision to child’s behavior
therapists. Consultants for Children, Inc. has a release to discuss relevant information with Child’s school and other therapy providers. (insert other
providers and services that the child receives).
TRANSITION PLAN
Child’s treatment plan will be supported by his/her parents, (Names), Lead Therapist, (Lead Therapist Name), and his/her behavior therapists. (Lead
Name) will review and analyze data on a monthly basis and will adjust programs accordingly. Progress reports will be provided quarterly to parents and
biannually to child’s resource coordinator.
DISCHARGE CRITERIA
Discharge will be considered upon mastery of the goals listed in this treatment plan and assessment that child has achieved age appropriate
development in all relevant domains. Progress toward achieving age appropriate levels may be measured by re-administering the (insert which
assessments were used) and through direct observation and data collected during therapy sessions. Changes to the patient's insurance eligibility may
also affect discharge plans.
PARENT TRAINING
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Parents will be provided with copies of the treatment plan and upon request, with corresponding skills program procedures. Parents will be requested to
facilitate generalization of skills at home, school, and in the community and will be instructed in implementation procedure and data collection. Parents
may request to observe sessions or to have a team meeting at any time.
HOURS RECOMMENDATION
Consultants for Children, Inc. recommends: 6 hours per month of Behavioral Consult and 8 hours per week of Behavioral Line services for child’s current
service plan year.
NOTIFICATION
Consultants for Children, Inc. has sent a copy of this treatment plan to (Case Manager Name) at (funding source) on or before 01/01/2015. (Lead
Therapist Name) has given a copy of this treatment plan to (Parent’s Name), and to child’s behavior therapists on or before 01/01/2015.
This plan will be reviewed and updated in six months of this date. If you have any questions regarding this treatment plan, please do not hesitate to
contact me at (720) 272-1289.
Name + Credentials
Consultants for Children, Inc.
(720) 272-1289
www.consultantsforchildren.com
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