APPLIED BEHAVIOR ANALYSIS THERAPY
Individualized Treatment Plan – Initial Assessment
Mail to:
Fax to:
Group Health Cooperative
Review Services
12400 East Marginal Way S AMB-2
Seattle, WA 98168-2559
1-800-377-8853
Attn: Review Services
Patient Name:
Group Health Consumer Number:
Date of Birth:
Age:
Male:
Female:
Patient Address:
Provider Name:
Provider Address:
Lead Behavioral Therapist:
Additional Care Team Names (unlicensed providers):
Referring Provider:
Diagnosis:
Name of Diagnosing Provider:
Date(s) of Initial Assessment:
Communication
Description of targeted behaviors and/or symptoms:
Objective initial measurement using standardized assessment to include, if appropriate frequency, intensity and duration:
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APPLIED BEHAVIOR ANALYSIS THERAPY
Individualized Treatment Plan – Initial Assessment
Describe how behavioral symptoms limit adequate participation in home, school or community activities and/or present a safety risk to self or
others:
Social Interaction
Description of targeted behaviors and/or symptoms:
Objective initial measurement using standardized assessment to include, if appropriate frequency, intensity and duration:
Describe how behavioral symptoms limit adequate participation in home, school or community activities and/or present a safety risk to self or
others:
Behavior (to include restricted, repetitive, and/or stereotypical patterns of behavior, interests, and/or activities)
Description of targeted behaviors and/or symptoms:
Objective initial measurement using standardized assessment measurement to include, if appropriate frequency, intensity and duration:
Describe how behavioral symptoms limit adequate participation in home, school or community activities and/or present a safety risk to self or
others:
Discharge Criteria and Discharge Plan:
Description of other current treatment programs (school based, medical based, community based):
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APPLIED BEHAVIOR ANALYSIS THERAPY
Individualized Treatment Plan – Initial Assessment
Other Relevant Information:
Individualized Treatment Plan
For each targeted area, describe the following:





Specific targeted goals and objectives including baseline performance with each goal; specific behavioral objectives that are
measurable; conditions under which it will happen
Type of intervention (both the instructional method used such as discrete trial learning, incidental learning, pivot response training, as
well as behavioral method used such as differential reinforcement of other behavior, extinction strategy)
Strategy for generalization of skills
Description of parental involvement
How treatment intervention is coordinated with school, special education, and/or other medical interventions (speech therapy,
occupational therapy)
Communication
Goal:
Intervention:
Generalization strategy:
Parental involvement:
How goal is coordinated with school and other treatment providers:
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APPLIED BEHAVIOR ANALYSIS THERAPY
Individualized Treatment Plan – Initial Assessment
Social
Goal:
Intervention:
Generalization strategy:
Parental involvement:
How goal is coordinated with school and other treatment providers:
Behavior (to include restricted, repetitive, and/or stereotypical patterns of behavior)
Goal:
Intervention:
Generalization strategy:
Parental involvement:
How goal is coordinated with school and other treatment providers:
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APPLIED BEHAVIOR ANALYSIS THERAPY
Individualized Treatment Plan – Initial Assessment
Number of requested hours of service per month for:
Lead behavioral therapist:
Unlicensed provider:
Supervision of unlicensed provider:
Parent training:
Group therapy:
Any other relevant information regarding treatment plan:
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