Behavioral Support Service Form Example - Wyoming Department Of Health
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1Behavioral Support Service Form Example
Behavioral Support Service includes training, supervision, or assistance in appropriate
expression of emotions and desires, compliance, assertiveness, acquisition of socially appropriate behaviors,
and the reduction of inappropriate behaviors through the implementation of positive behavior support and
interventions. This service can also be accessed for the intent purpose of reducing the use of restrictions and
restraints within a participant’s current plan of care or service environment.
th
Documentation of services must be submitted to the case manager by the 10
day of the following month
Agency Name
Name
Phone number
Agency Name:
Behavior Specialist Name:
Phone:
Case Manager
Last name
First name
Medicaid ID
Name
Participant Name:
Name:
Last
First
Medicaid ID
Service Checklist:
☐ Development of Functional Behavior Analysis (FBA)
☐ Development of Positive Behavior Support Plan (PBSP)
☐ Training staff, family members, roommates, and other appropriate individuals for implementation of PBSP
☐ Training participant in assertiveness
☐ Training participant in stress reduction techniques
☐ Training participant in acquisition of socially acceptable behaviors
☐ Training participant on essential elements of PBSP for the purpose of developing adaptive skills
☐ Consultation with participant and team members
Submit Documentation that provides detailed information on behavior supports
Board Certified
Behavior Analyst
Task
Outcomes
Schedule
Hours
Number
Total
Rate
Total
or other certified
Per
of
Hours
professional
Week
Weeks
Behavior
Development
Observation and
Week
8
2
16
Specialist
of FBA
development of FBA
1 and 2
within the participant’s
environment
Behavior
Development
Review FBA and consult
Week 3
8
1
8
Specialist
of PBSP
with participant and
team to develop PBSP
Behavior
Consultation
Review data collected by
Week 4
8
1
8
Specialist
with
waiver providers and
participant
meet with participant
and team
and team to discuss
members
results and amend the
PBSP as needed
Total
Cost
3/2014
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