Home Expectations & Environmental Inventory
It is our responsibility to ensure that it is a safe and clean environment to work in. Additionally, for in-home service to be most effective, we must ensure that there are ample games/supplies/toys present for us to engage with during treatment. If there are not enough supplies to support the ABA in-home program, the patient may be referred out to a different provider.
Please complete the questions below to give us more information about the home environment.
Patient Name
First Name
Last Name
Does anyone smoke inside the house? If so, are they willing to stop smoking inside while the RBT is present?
*
Yes
No
Does anyone in the home have an infectious disease or illness such as chicken pox, measles, or tuberculosis?
Yes
No
Does the home have a wide variety of age-appropriate toys and games that the child is interested in? (Board games, building blocks, puzzles etc.) This is required so that the ABA program and reinforcement in the natural environment can work.
Yes
No
Other
Does the home have an outdoor play area?
Yes
No
Other
Does the home have a wide variety of basic school supplies (table, crayons, paper, glue, child scissors etc)?
Yes
No
Other
Are there any firearms in the house? (If so, please indicate if they are locked up)
Yes
No
If fire arms are present in the home, are they locked and stored properly?
Yes
No
Is there cell phone coverage in the area?
Yes
No
Is there any reason why a provider may be unsafe when visiting your home? If Yes, please explain...
Yes
No
Do you have any animals in the home?
Yes
No
If animals are present, are they up to date on all recommended vaccines?
Yes
No
If animals are present, have they been aggressive?
Yes
No
If animals are present, and if needed, would animals be able to be moved to another part of the house?
Yes
No
Parent Name
First Name
Last Name
DateTime
Parent Signature
Submit
Should be Empty: