bbbinterventions · Web view2014. 7. 31. · 3) ABLLS-R, FBA, or VB-MAPP completed by BCBA or...

Building BlocksBehavior Interventions, LLC

Orlando, Florida www. bbbinterventions.netPhone: (267)597-1029Fax: (407)203-3199Email:[email protected]

In-Home ABA Program Intake Packet

Welcome!

Thank you for selecting Building Blocks to help you meet the needs of your child. We look forward to working with you and your loved one during this important process.

The attached packet contains information that will inform you about Building Blocks Behavior Interventions LLC’s philosophy, services, payment options, policies, and procedures. An intake questionnaire has been provided in order to get to know you and your child better prior to your interview. The more information that you provide, the better we will understand the needs of you and your child. We understand that some of these forms may be time consuming, and challenging. If you have any questions or concerns please feel free to contact us at any time.

Thank you for your trust that you are placing in us to assist you in starting ABA therapy. We look forward to meeting with you and your child.

Sincerely,

Building Blocks Behavior Interventions, LLC

mailto:[email protected]


What is Required to Start In-Home ABA Services?

1) Completed In-take Packet- Child & Adolescent Intake Questionnaire- HIPPA Service Agreement and Consent Form- Patient Confidentiality Contact Form

- Financial Agreement Form- Request/Authorization to Release Confidential Medical & Mental

Health Records and information

2) In-Take interview/Assessment with a BCBA or BCaBA (2-4 hours)*Step 1 must be complete prior to scheduling interview

3) ABLLS-R, FBA, or VB-MAPP completed by BCBA or BCaBA

4) Meeting with ABA tutor to review treatment goals and program plan

5) Arrangement of schedule for In-Home Therapists


An Overview of Building Blocks Behavior Interventions, LLC’s

Our philosophy:At Building Blocks, we believe that every child has the ability to reach his or her optimal

level of ability. It is our responsibility to create a learning environment using positive teaching methods that are tailored to meet each child’s unique needs. Building Blocks will only use up-to- date behavior interventions that are supported by scientific research in the field of Applied Behavior Analysis.

Our programs focus on:- the strengths of each child- building the foundation to an independent functional life- increasing social skills for peer relationships- teaching age appropriate play skills- strengthening expressive and receptive language - positive and enjoyable atmosphere for the learner- a mix of teacher directed and student initiated activities

Our Services:Building Blocks offers direct 1:1 therapy for individuals with disabilities of all ages in a

home, school, or community setting. Our trained Behavior Therapists, BCaBAs, and BCBAs will closely assess each child’s strengths and needs in the areas of life skills, language, social skills, and academics through indirect and direct assessments. Based on the findings, a unique –custom designed program will be developed. The program will include a variety of behavior analytic procedures supported by scientific research including Positive Behavior Support, Incidental and Natural Environment Teaching, Discrete Trial Training, Story Based intervention, and Pivotal Response Training.

All our therapists hold at least a bachelors degree or have equivalent extensive training specifically in research supported treatments for autism spectrum disorders. Supervision of each child’s program is provided by either a BCBA or BCaBA.

We provide behavioral assessments, parent & staff training, program supervision, and quality monitoring for VBMAPP or ABLLS programs. Each of our program supervisors are board certified by the Behavior Analysis Certification Board™.

Please call 267-597-1029 for further information or clarification.


Financial Information

Currently we accept the following insurances:

CIGNAAETNA

Private Pay clients can reach us for more information on rates by calling us at 267-597-1029

We accept all major credit cards. Payment is due by the end of the month. Payments can be made via mail, phone, or online. Direct payment may also be available through your bank.

There is a $40 Returned Check fee for all checks returned by the bank.

Information Related to Scheduling and Sessions

Each case has an ABA tutor designated as the lead person for your family. Each Associate has at least a Bachelors degree and experience providing services to children with Autism. All cases are overseen by a Board Certified Behavior Analyst or Board Certified assistant Behavior Analyst.

Sessions for in-home ABA usually scheduled in two-three hour blocks. The research is clear that longer sessions result in greater retention and this makes scheduling more convenient for all parties. If this is not convenient for your family, please bring this up during at the intake meeting.

A parent or legal guardian is required to be present and available in the home throughout the therapy session(s).

Except in cases of emergency, 24-48 hours notice is required for all cancelled appointments. Payment for the appointment is required for all missed appointments not cancelled according to this policy. Insurance carriers are not responsible for miss-appointment fees.

We request that families give us at least two weeks notice on significant changes in their plans for ABA sessions scheduling in order to facilitate consistency in service delivery.

The universal standard for therapy, be it the insurance standards or the professional standards of various organizations like the APA, ASHA, etc., is that a therapy: “hour” is 45-50 minutes of direct contact with the patient with the remaining 10-15 minutes devoted to required record keeping and other administrative requirements. Typically, for a 3 hour in-home therapy session, our staff take ~10 minutes to arrange the materials prior to commencing direct therapy with the child and ~ 15 minutes at the end to record data, tidy the setting, and discuss the session with the parent.

The standard of care outlined in the ABA International’s Revised Guidelines for Consumers of Applied Behavior Analysis Services to Individuals with Autism includes supervision of therapists on an ongoing basis, program consultation, program review, and program revision as services performed by a BCBA. These services are necessary for a program to meet minimum professional standards and are not optional

Parent participation will be critical in the progress that your child makes. If parents do not follow through with treatment plan; Building Blocks Behavior Interventions, LLC will not continue services.


CHILD & ADDOLESCENT INTAKE QUESTIONNAIREConfidentialThe following questionnaire is to be completed by the child’s parent or legal guardian. This form has been designed to provide essential information before your initial appointment in order to make the most productive and efficient use of our time. Please feel free to add any additional information which you think may be helpful in understanding your child. Building Blocks Behavior Interventions, LLC will hold information provided by you is strictly confidential and will only be released in accordance with HIPPA guidelines and as mandated by law. Please use the backs of the pages for additional information.

PLEASE PRINT

Name of Person Completing this form: ________________________________________________

Legal Name of Child/Adolescent: ____________________________________________________

Nickname or name child routinely goes by: ____________________________________________

Child’s Date of Birth: ____________________________________ Age: _____________

Home Address: ___________________________________________________________________ Street

__________________________ ___________________ _______ _______ City County State Zip

Home Telephone Number: ___-___-____ Work Phone(s) Mother: ____-____-______ Father: ____-____-______Cellular Phone(s) Mother: ____-___-____ Father: ____-___-____

School Name:__________________________ System: _______________________ Grade: ______

School Telephone Number: ___________________________________________________________

Current Teacher(s): _________________________________________________________________

Who referred you to our practice? _____________________________________________________


Please describe the problems your child is now having, and what type of services you are seeking from us for these problems. Please use the back of this page for additional space.

INDICATE PARENT/GUARDIANS LIVING IN THE HOME:

Marital Status: Married – Remarried – Divorced – Separated – Widowed – Single – Cohabitants

If divorced, who has physical custody? ________________ Is it full or joint?________ Who has legal custody? ______________ Is it full or joint? ______________________ If divorced, please provide a copy of the custody agreement.

Mother’s Name ________________________________________________________________Date of Birth: ______________________________ Age: ______________Occupation: ______________________________ email:Employer: ______________________________ (If Military) rank:Education Completed ___________________ Health: ___Excellent ___ Good ___ Fair ___ Poor

Does either parent’s job require him/her to be away from home long hours or extended periods?

________________________________

Father’s Name ________________________________________________________________Date of Birth: ______________________________ Age: ______________Occupation: ______________________________ email:Employer: ______________________________ (If Military) rank:Education Completed ___________________ Health: ___Excellent ___ Good ___ Fair ___ Poor

Does either parent’s job require him/her to be away from home long hours or extended periods? ________________________________

Siblings:

Name Age Relationship Living in same house? _____________ _____ _____________ Y/N

_____________ ______ _____________ Y/N


Name Age Relationship Living in same house?

_____________ ______ _____________ Y/N

____________ ______ _____________ Y/N

Please list additional Sibling in the above format on the back of this page.

Has the child you are seeking services for been evaluated in the past? Yes/NoIf Yes, please list the following information on the previous evaluation(s)Who Type When Copy Available__________________ __________________ __________________ Y/N__________________ __________________ __________________ Y/N__________________ __________________ __________________ Y/N__________________ __________________ __________________ Y/N

(If more evaluations need to be listed please use the space on the back of this page.)

If yes, what were their general findings and recommendations? __________________________________________________________________________________________________________________________________________________________________________________________________________________

Please provide us with any other information on the psychological history that you feel would be helpful to us in understanding your child: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


PRE-NATAL AND DELIVER HISTORY:Were there any complications with the Pregnancy? Y/N_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________If Yes, please provide treatment details: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Concerns at Birth? Y/NIf Yes, please provide detail – including any treatments given (Additional space on back if needed):__________________________________________________________________________________________________________________________________________________________________________Is there any additional pre-natal or birth information that might be of assistance to us?__________________________________________________________________________________________________________________________________________________________________________DEVELOPMENTAL HISTORY : 1. Please indicate the age at which your child did the following:

Said 1st Word Intelligible to strangers ____________

Said two-three word phrases ____________

Used Sentences regularly ____________

Toilet trained during the day ____________

Dry through the night (6+ months) ____________

Dressed Self ____________

2.Please indicate if your child is experiencing any of the following:

Problems with eating ____________Isolated socially from peers ____________Problems making friends ____________Problems keeping friends ____________Problems controlling temper ____________Problems sleeping through the night ____________Nightmares ____________ Bed Wetting ____________Anxiety ____________Unmotivated ____________School concentration difficulties ____________


List any operation, serious illnesses, injuries (especially head), hospitalizations, allergies, ear infections, or other special conditions your child has had. __________________________________________________________________________________________________________________________________________________________________________

List any medications your child is currently taking or has taken for extended periods (give dosage level if possible): ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________With which hand does the child write: _____________________________________________________________________________________Does the child have any vision problems? ______________________________________________________Does the child have any hearing problems? __________________________________________________________________________________________________________________________________________________________________________Name of child’s physician(s) ___________________________________________________Practice Name: _____________________________________________________________Address: ____________________________________________________________________________________________________________________________________________Phone Number: __________________________________ Fax Number: _______________

(Please list information on additional Physicians on the back of the page)

EDUCATION HISTORY:1. List the schools you child has attends:

Name System Year(s) Grade Special Ed?

2. Name(s) of current teacher(s) ________________________________________

3. Does your child’s teacher have concerns about him/her (list) _______________

_________________________________________________________________

4. What is your child’s favorite subject/class? _____________________________


5. What is your child’s least preferred subject/class? _______________________

6. Has your child ever repeated a grade? Y/N If yes, what grade(s)?: ___________

7. If your child has been in Special Education, did they have a:

504 Plan

I.E.P.

Psychological Evaluation

Special Evaluation

Behavior Intervention Plan

Occupational Therapy Evaluation

Physical Therapy Evaluation

Adaptive Technology Evaluation

Other(s)

8. If your child has been in Special Education, how were they served?

Consultation

Collaborative Education

Pull-Out

Special Program

Resource Classroom

Team Taught Classes

Self-Contained Classroom


9. Child’s extracurricular activities, including sports, clubs, hobbies, lessons, etc.:

_____ Football _____ Karate ____ _Dance (type) ___________________ _____ Baseball _____ Piano _____ Music (type) ___________________ _____ Cheerleading _____ Scouts _____ Gymnastics (type) _______________ _____ Basketball _____ Soccer _____ Other(s): _______________________

10. List any special abilities, skills, strengths your child has: _____________________________

______________________________________________________________________________

DISCIPLINE INFORMATION

Parents may use a wide range of discipline strategies with their children. Listed below are several examples. Please rate how likely you are to use each of the strategies listed:Intervention Very Unlikely Very Likely EffectivenessLet situation go 1 2 3 4 5 ________ ________

________ ________Take away a privilege (i.e., no TV) 1 2 3 4 5

________ ________Assign an additional chore 1 2 3 4 5

________ ________Take away something material 1 2 3 4 5

________ ________Send to room 1 2 3 4 5

________ ________Reason with child 1 2 3 4 5

________ ________Ground/ Time Out 1 2 3 4 5

________ ________Argue/ Yell 1 2 3 4 5

________ ________List anything else you may do:________________________ 1 2 3 4 5 ________ ________________________________ 1 2 3 4 5 ________ ________________________________ 1 2 3 4 5 ________ ________

Go back and rate the THREE MOST effective strategies. That is, place a 1 by the most effective, a 2 by the next most effective, and a 3 by the third most effective. Please circle the LEAST effective. Please rate what percentage of discipline is handled by each of the following:Father:_____% Mother:____% Other: _____% (Please Specify:)______________________________


GENERAL INFORMATION:

Please list the five things you would like for your child to do more of and less of in order of priority to you. For example, instead of saying, “I want my child to be more responsible,” translate that into actual behaviors such as do household chores, care for brothers and sister, etc.

Like Child to do More Often Like Child to do Less Often

1. ___________________________ _____________________________

2. ___________________________ _____________________________

3. ___________________________ _____________________________

4. ___________________________ _____________________________

5. ___________________________ _____________________________

ACADEMIC:

Do you feel your child’s academic skill level is appropriate? Y/NWould you like us to address academic skills development?

Y/N Can your child identify letters?Lowercase ____all _____some _____noneUppercase ____all_____some _____noneCan your child identify numbers?Single digit (1-9) ____all ____some _____noneCounting:Can count to 10 Y/N Can count to 20 Y/N Can count 20+ Y/NCan your child count out a number of objects (e.g. Give me four pennies)Up to 5 objects Y/N Up to 10 objects Y/N 10 + objects Y/NCan your child identity double digit numbers? 10-99 ___all ____some ____none Can he/she complete simple addition math problems? (Single digit) Y/N Can he/she complete simple subtraction problems? Y/N


Letter sounds:Can your child: Identify letter sounds ____all ____some ____none Identify blends (e.g. sh, st, cr) Y/N Can sound out words with blends Y/NReading:Can read simple words (2-4 letter simple words – cat, dog, sat) Y/N Can read longer words and sight words (there, just, jump) Y/NCan sound out unknown words Y/N Can read simple sentences Y/N Can comprehend what he/she is reading (can understand and answer questions about what’s been read) Y/NOther number skills:

Reading Comments:

SELF CARE: Does your child dress him/herself? ____Independently ____with some assistance ____ does not dress self Does your child bathe him/herself? ____Independently _____ with some assistance ____ does not bathe self Grooming (brushing teeth, combing hair) ____ independently ____some assistance ___does not Does your child clean up after him/herself ____ independently ____ when asked ____ does not Do you have safety concerns regarding your child’s activities at home? Y/NExplain: ____________________________________________________________________ ______________________________________________________________________

ATTENDING/ENGAGEMENT:Does your child make eye contact with others ____always ____sometimes _____never Answer or look when name is called ____always ____sometimes _____never Respond with distraction:

Can your child answer questions when there is background noise, other people, distraction?____always _____sometimes _____rarely


Auditory processing:Does your child appear to understand directions and questions? ____strength ____challenge Can your child appropriately play by him/herself ? Y/N Does your child appear to have a good memory? Y/NSelf-Care Comments:

Attending Comments:

BEHAVIOR: Physical Stereotypic Behavior:Does your child flap his hands/arms Y/N Does your child seem to look at his fingers in a stereotypic way Y/N Does your child seem to look out of the side of his/her eyes Y/N Does your child walk on his/her toes Y/N Does your child rock (sit and rock back and forth) Y/NVerbal Stereotypic Behavior:Echolalia – repeats what is said/heard – Immediate Y/N Echolalia – Delayed – (will repeat what’s been said/heard later) Y/N Self-talk Y/N Humming to self – inappropriate Y/N Screech or yell inappropriately Y/N for no apparent reason Y/NPerseveration:Does he/she get stuck on a topic Y/N Get obsessive about specific people Y/N Get obsession about specific objects Y/NTransition/Routines:Fears:Has trouble with sudden change Y/N Has trouble with changes that they are warned about Y/NDoes your child fear any specific objects, animals, places or people? Y/NIf yes, explain _____________________________________________________

Tantrums/Aggression/Self-Injury: Does your child have tantrums that you feel need to be address? Describe behavior: ______________________________________________________________________________ ________________________________________________________________________


______What triggers a tantrum?When told “no” (you can’t have that/can’t do that) Y/N When he/she is not getting attention or wants attention Y/N To avoid a non-preferred activity Y/N To escape a non-preferred task/activity Y/N For no obvious reason Y/NDoes your child react aggressively at times?Describe aggressive behaviors:______________________________________________________________________________ ______________________________________________________________________________

Is this behavior disruptive enough that you feel it needs to be addressed?What triggers aggressive behavior? When told “no” (you can’t have that/can’t do that) Y/N When he/she is not getting attention or wants attention Y/N To avoid a non-preferred activity Y/N To escape a non-preferred task/activity Y/N For no obvious reason Y/NDoes your child engage in Self-injurious behavior (hurt himself or herself)?Describe self-injurious behavior: _____________________________________________________________________________ _____________________________________________________________________________What triggers self injurious behavior?When told “no” (you can’t have that/can’t do that) Y/N When he/she is not getting attention or wants attention Y/N To avoid a non-preferred activity Y/N To escape a non-preferred task/activity Y/N

For no obvious reason Y/NSENSORY ISSUES: Does you child have sensitivity to (if yes explain):Behavior Comments:___Sound ___Light ___Touch ___Texture ______________________________________________________________________________________________________________ _______________________________________________________


_______________________________________________________Sensory Comments:

IMITATION OF MOVEMENTS AND SPEECH:Can imitate movements when they are demonstrated (clap hands, touch head when someone else is doing the same and he/she is asked to “do this” or “clap hands”) Y/N Can imitate motions that go along with a song Y/N Can imitate a word or words when told to “say ____” Y/N

SPEECH: Do you have concerns regarding dyspraxia or apraxia? Y/NIf yes explain __________________________________________________________________Does your child repeat what he/she has heard other people or TV characters say? Y/N If yes explain _________________________________________________________________Does your child use a communication system such as PECS, sign, augmentative device, etc? Y/N If yes explain _________________________________________________________________LANGUAGE: Does your child appear to understand language? ___no at all ____ a little ____this is a strengthWords in isolation – can identify objects when asked Y/N Can identify actions (“where is the boy who is running” when shown a pictures of kids playing) Y/N Can identify describing words (red vs. blue, big vs. little) __not at all ___ a little ___strength Can understand simple sentences (“drink your milk.”) Y/N Can understand more complex sentences (“go get your red shoes,” or “give me the one that is not wet”) Can he/she follow directions? Y/N - ____one step ____two step ____three step____with delay (“after you finish eating, go get your shoes”)Imitation Comments:

Speech Comments:

Language Does your child use the following when speaking:


Nouns (people, places and things) ___sometimes ____always ___never

Verbs (action words) ___sometimes ____always ___neverAdjectives (describing words) ___sometimes ____always ___neverPrepositions (in, out, on etc.) ___sometimes ____always ___neverPronouns (I, you, she, he) ___sometimes ____always ___neverSimple sentences (3-4 word) ___sometimes ____always ___neverSentences w/descriptors (“It’ s a black dog”) ___sometimes

____always ___never

Expressive Communication: Does your child use language? To request needs/wants ___sometimes ____always ___never ___To greet others sometimes ____always ___neverTo respond to greetings ___sometimes ____always ___neverAnswer simple questions (what’s your name?) ___sometimes

____always ___never

Language Comments:

SOCIAL/PLAY: Does your child seek out social interaction with: ___adults ____siblings ____peersDoes your child play:Independently ___sometimes ____always ____neverNext to but not with others ___sometimes ____always ____neverWith other children ___sometimes ____always ____neverWith toys ___uses appropriately ___does not play with as intendedGame skills – plays games ___turn taking independently ___needs assistance ___ independentlyVerbal skills ___talks to peers during play ___ talks to self ___ does not talkSocial Comments:

FINE MOTOR SKILLS: Is your child ____left handed ____right handed ____no

preference Does your child hold a pencil properly? Y/N Can he/she: Trace Y/N Copy letters Y/N Copy words Y/N


GROSS MOTOR SKILLS: Do you have concerns regarding your child’s gross motor

skills? Y/NExplain:

____________________________________________________________________

PARENT/FAMILY PRIORITIES & PREFERENCESTop three areas/goals you would like to see change for your child in next 6 months:

1.

2.

3.

INTERVENTION STYLES In order to accomplish goals set for your child, we rely on a variety of research-based methods and styles. We assess your child’s needs and employ methods that will maximize your child’s skill acquisition. Below you will see a list of various styles.

We would like to understand your familiarity with each intervention type as those you think may think would work best for your child’s personality/needs at this time. Pleases note that this is NOT an exhaustive list of methods.

DK = *DON’T KNOWSTYLE/METHOD Familiar

with style/method?

May use with my child?

additional comments:

Errorless learning (teaching without allowing errors)

Y N DK Y N DK

Fluency based instruction/precision teaching

Y N DK Y N DK

Functional Communication Training

Y N DK Y N DK

Incidental Teaching (following child’s lead)

Y N DK Y N DK


around the houseIncidental Teaching (following child’s lead) in structured play

Y N DK Y N DK

One-to-one intervention (discrete trial) at desk or table

Y N DK Y N DK

PECS (Picture Exchange Communication System)

Y N DK Y N DK

Peer play dates Y N DK Y N DKPositive Behavior Support – working through behaviors and replacing behaviors with appropriate skills

Y N DK Y N DK

Self-management plans (for behavior – other skills)

Y N DK Y N DK

Sign Language Y N DK Y N DKSocial Groups Y N DK Y N DKUse of food as “reinforcer” (with the intent to fade as quickly as possible – we only use as a place to “start” if needed)

Y N DK Y N DK

SUPPORTING BEHAVIORS:

Sometimes when teaching our students appropriate replacement behaviors, students may become upset or cry. When this happens, we are very adept at working through these instances with favorable outcomes. We want to understand how you feel about this when it happens. (Please note that all behavior support plans are discussed with parents and strategies for responding are explained and approved. Providers can debrief parents after any “difficult” sessions as well.)

______I am comfortable with letting my child cry and letting providers handle the situation ______I am NOT comfortable with letting my child cry and letting providers handle the situation ______ I am unsure at this time

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