Form Dmas-355 - Virginia Treatment Referral Information - Department Of Medical Assistance Services Page 2

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3)
Assistive Technology evaluation and recommendation:
4)
Recommendations for the development of a focused ABA therapy program specific for the child:
5) Discharge Criteria:
Intensive in-home behavior therapy/ ABA ______ Hours weekly.
Attending
Physician:_____________________Signature:____________________________Date___/___/______ 
DMAS‐355 
9/10/2008 
 

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