Applied Behavior Analysis (Aba) Service Request Form - Bluecross Blueshield Of New Mexico Page 2

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Applied Behavior Analysis

(ABA) Service Request Form

What has response been to therapy? c Poor c Moderate c Excellent

Have the symptoms that brought the member initially to treatment been resolved? c No c Yes

Indicate the level of parental/caregiver participation: c None c Minimal c Moderate c Optimal

# of participation hours/week _______________

Describe the level of support/involvement by the member’s family or support system: ______________________________________________________________

_______________________________________________________________________________________________________________

age appropriate Developmental Functioning Level - Where is this member’s current functioning?

Based on the member’s age, he/she has established developmental milestones/functioning that should have been acheived by that age,

Very

if not for their autism symptoms. Please put an ‘X’ in one of the spaces to the right of each area below indicating where the member is

poor

Fair

Good

currently in regards to those milestones or age related functioning.

speech/Language/Communication - Manding/Tacting/Intraverbals/Listener Skills/Expressive Language Skills

sociability - Social Skills/Social Behavior/Social Play/Classroom Routine/Group Skills

sensory/Cognitive awareness - Visual Perceptual Skills/Matching to Sample/Imitation/Independent Play

health/physical/Medical stability - Motor Imitation Skills/Fine Motor Skills

Behavior stability - Behavior/Compliance/Appropriate Adaptive Behavior Skills

Current significant Maladaptive Behaviors (Frequency per day or week):

1. Behavior:____________________________Freq._______ /_______ 2. Behavior:___________________________Freq._______ /_______

3. Behavior:____________________________Freq._______ /_______ 4. Behavior:___________________________Freq._______ /_______

Other supports Outside aBa Treatment

Please indicate below the member’s other supports outside of the ABA treatment:

Is this member accessing other program services? c School Based c Educational c Other c NA

Please describe those program services: ________________________________________________________________________________________

Is this member accessing other therapeutic services? c Physical Therapy (PT) c Occupational Therapy (OT) c Speech Therapy (ST) c NA

Describe how you have coordinated care with other medical and behavioral health providers such as primary care physician, pediatrician, psychiatrist or therapist. Please indicate if the client has

refused this contact: ___________________________________________________________________________________________________

_______________________________________________________________________________________________________________

Please describe the community or support services that this client/parent/guardian has accessed or that may be available to the client/parent/guardian: _______________________

_______________________________________________________________________________________________________________

Current Treatment plan

Please describe the member’s discharge plan:___________________________________________________________________________________

_____________________________________________________________________________________________________________

For Continued stay requests:

Measurable Goals

Interventions to achieve Goals/

Domain of Treatment Focus

Please indicate progress made since last treatment

with Timelines

Overcome Barriers

(include all that apply)