Applied Behavior Analysis Therapy Progress Report
Mail to:
Kaiser Permanente
Review Services
2715 Naches Ave. SW, Mail Stop GSW-A3S05
Renton, WA 98057
Date of Progress report:
Patient Name:
Kaiser Permanente Member number:
Date of Birth: Age: Male Female
Patient Address:
Provider Name:
Provider Address:
Lead Behavioral Therapist:
Additional Care Team Names (unlicensed providers):
PROGRESS TOWARDS INDIVIDUAL GOALS:
· Provide descriptive overall summary of how patient is making functional and measurable progress as pertains to social communication and/or social interaction, restrictive/repetitive/stereotypical patterns of behavior or other adaptive behaviors:
· How many goals were met over past six months:
· How many goals were improved over past six months:
· How many goals were not met over the past six months:
· How many goals did patient regress:
· For goals that have not been met or patient regressed, provide summary of reasons for goals that have not been met and an overview of how goals and/or interventions are being revised to meet goals:
· New goals (if there are new goals, provide goal, baseline, timeline for mastery, and generalization strategy:
Goal(s):
Baseline:
Anticipated Timeline for Mastery:
Generalization strategy:
Goal(s):
Baseline:
Anticipated Timeline for Mastery:
Generalization strategy:
Goal(s):
Baseline:
Anticipated Timeline for Mastery:
Generalization strategy:
PROGRESS TOWARDS PARENT TRAINING GOALS:
Provide descriptive overall summary of functional and measurable progress is occurring as it pertains to parent goals particularly as it pertains to transferring interventions from the individual to the parent. Include description of level of participation of parent/legal guardian in treatment.
· How many goals were met over past six months:
· How many goals were improved over past six months:
· How many goals were not met over the past six months:
· How many goals did patient regress:
· For goals that have not been met or patient regressed, provide summary of reasons for goals that have not been met and an overview of how goals and/or interventions are being revised to meet goals:
· New goals (if there are new goals, provide goal, baseline, timeline for mastery, and generalization strategy:
Goal(s):
Baseline:
Anticipated Timeline for Mastery:
Generalization strategy:
Summary of Coordination with School and/or other treatment providers:
· What occurred to coordinate ABA treatment with IEP/school based intervention with over the past six months:
· What occurred to coordinate ABA treatment with other providers (Speech, PT/OT, Medical, Mental Health, Community):
· If patient has been in treatment for one year, provide reassessment of patient’s developmental status and how patient has progressed as compared to previous developmental assessment:
· Describe how patient is progressing towards discharge. How does patients current status compare to measurable discharge criteria (ability to adequately participate in home, school, or community activities, transition to less intensive level of care):
Any other relevant information:
Number of requested hours of service per month for:
Lead behavioral therapist:
Unlicensed provider:
Supervision of unlicensed provider:
Parent training:
Group therapy:
Total number of hours requested:
1