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Today's Date
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Month
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Day
Year
Date
Child's Name
First Name
Last Name
Child's Birth date
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Month
-
Day
Year
Date
Child's Gender
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Area Code
Phone Number
Child's Primary Diagnosis and Date of the diagnosis
Name of the M.D. who provided the diagnosis
Other diagnosis and date's of each diagnosis
Name of M.D. who provided additional diagnosis
Upload a copy of the prescription with the referral for ABA services
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Upload a copy of the full diagnostic report from the diagnosing physician. (Please check that you are uploading the report and not notes from the appointment.). Please scan all pages and upload as one document.
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Please upload a letter from your physician recommending ABA. If you do not have a letter, please have your M.D. follow the following format when writing your letter: Name of Child: Date of Birth: Diagnosis: F84.0: Evaluate and treat: Intensive Applied Behavior Analysis (ABA) to be provided per a treatment plan and program written and supervised by a BCBA. Hours required: ______hours per week of direct ABA with all necessary hours of Supervision, Evaluation, Re- Evaluation performed by a BCBA directly. Treatment is medically necessary Treatment period: __/__/2021 - through -/__/2022. Please scan all of the above in one document prior to uploading.
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Funding Source for ABA services
Private Insurance
Private Pay
Medical Insurance Provider
Medical Insurance Policy Number
Medical Insurance Group Number
Upload a copy of the front of your medical insurance card
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Upload a copy of the back of your medical insurance card
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Name of the primary insurance holder
Date of birth of the primary insurance holder
Social Security number of primary insurance holder
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Mother or Legal Guardian's Full Name
First Name
Last Name
Relationship to the child
Address ( if different from child's)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home phone
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Area Code
Phone Number
Mobile phone
-
Area Code
Phone Number
Email
example@example.com
Highest grade completed
Occupation
Employer
Father's or Legal Guardian's Full Name
First Name
Last Name
Relationship to the child
Address ( if different from the child's)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home phone
-
Area Code
Phone Number
Mobile phone
-
Area Code
Phone Number
Email
example@example.com
Highest grade completed
Occupation
Employer
Have both parents or legal guardians been made aware the ABA services are being pursued?
Yes
No
Are there any immediate family member been court ordered to mental health or chemical dependency treatment?
Yes
No
Is any immediate family member under department of corrections supervision?
Yes
No
Does any immediate family member have a history of substance abuse, including tobacco?
Yes
No
Does any immediate family member have a history of pathological gambling?
Yes
No
Has any immediate family member been identified to be at risk of harm to self and/or others, including suicide and/or homicide?
Yes
No
Is there a history of trauma or abuse with any immediate family member?
Yes
No
Does the child have any history of trauma or abuse?
Yes
No
Does the child have any siblings?
Yes
No
If so, please provide their name, age, and gender ( If not, enter N/A)
Is the client currently in Birth-3 Services?
Yes
No
Is the child currently enrolled in school?
Yes
No
If in school, what setting is your child currently enrolled in?
Self-contained
Inclusion
General Education
Please upload the child's IFSP or IEP. If neither available, submit a document that states that the child does not have either. Please scan the entire document to one file prior to uploading.
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Does your child have any medical issues (i.e. seizure disorders, immunocompromised, etc.)
Yes
No
If yes, please describe the medical condition ( If not, please enter N/A)
Does your child take any medication (i.e. prescribed, over- the -counter, vitamins, etc.)
Yes
No
Please enter the dosage, times when administered, and for what is it used for?( If no meds, please enter N/A)
Has the child ever been admitted to a hospital/treatment center for psychiatric, behavioral, orcrisis situations?
Yes
No
Are there any medical conditions that need to be considered when delivering ABA treatment?( i.e. difficulty walking, sitting, sleep disorders, feeding and swallowing difficulties etc.
Yes
No
If yes, please explain. ( If no, enter N/A)
What intervention modalities has your child received? Check off all that apply
ABA
DI
Floor Time
Pivotal Response Training
RDI
Speech Therapy
Occupational Therapy
Vision Therapy
Hearing Services
My child has not obtained services
Please describe when each kind of service modality was begun and ended and/or are still currently receiving and its outcomes.
History of Treatment- Please describe how many hours were provided weekly for each service modality that the child is current receiving or was receiving in the past.
If your child has a history of receiving ABA services, please upload all graphs for behavior analysis programming and/or behavior reduction from the last 3 months and all assessment and programming reports. If you receiving treatment with another model, please upload all assessments, reports, or notes available. Please scan and upload as one document.
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Please check off any items that apply to your child
Tantrums/meltdowns
Elopement
Aggression
PICA ( ingesting non-edible items)
Mouthing ( placing non-edibles in on or in mouth but not ingested)
Echolalia
Sleep Difficulties
Feeding Difficulties ( food selectivity)
Dysphagia
Bathing Difficulties ( washing body, washing hair, etc.)
Self-injurious/self-harm behaviors
Hyperactivity
Allergies
Gastrointestinal issues
Unaware of danger
Impulsive ( engages in behavior without warning)
Does not show interest in other children
Plays next to children but not with children
Executive Functioning (flexibility, organization, attention)
What current communication skills does your child have (ex. Sign language, PECS, Vocal, Augmentative device, gestures)?
Please list the top three areas/goals you would like to see improvement for the client in next 6 months:
List your child's strengths.
List what are things your child enjoys.
Please describe below important cultural practices, rituals, traditions or beliefs that you believe are important for us to be aware of prior to initiating a therapeutic relationship.
Are both parents available to participate in parent training?
Yes
No
The Bedrock Clinic & Research Center, Inc. is a non-profit 501c3. Are you willing to actively fundraise for our organization?
Yes
No
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