APPLIED BEHAVIOR ANALYSIS THERAPY
Individualized Treatment Plan – Initial Assessment
Mail to:
Kaiser Permanente
Review Services
2715 Naches Ave. SW, Mail Stop GSW-A3S05
Renton, WA 98057
Fax to:
1-800-377-8853
Attn: Review Services
Phone: 1-206-630-1854
Date of 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):
Date(s) of Initial Assessment:
Developmental level (i.e. social, language, communication, and adaptive behavior) of patient using standardized
assessment tool (i.e. Vineland, VBMAPP):
Social Communication and Social Interaction:
Description of targeted behaviors and/or symptoms:
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APPLIED BEHAVIOR ANALYSIS THERAPY
Individualized Treatment Plan – Initial Assessment
Describe how social communication and social interaction symptoms limit adequate participation in home, school or community
activities and/or presents a safety risk to self or others.
Restrictive/Repetitive/Stereotypical patterns of Behavior (i.e. stereotyped/repetitive motor movements, insistence on
sameness, inflexible adherence to routines, highly fixated interests, hyper/hyporeactivity to sensory input)
Description of targeted behaviors and/or symptoms:
Describe how behavioral symptoms limit adequate participation in home, school or community activities and/or presents a safety
risk to self or others.
Other areas of concern (if there are other targeted areas of concern such as adaptive/functional deficits, please
describe these concerns and how patient’s autistic symptoms are impacting these deficits):
Description of current IEP/school based program:
Description of other current treatment programs (Speech, OT/PT, Medical, Mental Health, Community):
Individualized Treatment Plan
For each targeted area, describe the following:
 Specific targeted goals and objectives including baseline performance with each goal; specific behavioral objectives that are
measurable, conditions under which it will happen;
 Strategy for generalization of skills:
Social Interaction Social Communication/Interaction (i.e. social-emotional reciprocity, nonverbal communication, developing,
maintaining, and understanding relationships):
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APPLIED BEHAVIOR ANALYSIS THERAPY
Individualized Treatment Plan – Initial Assessment
Goal(s):
Baseline:
Intervention:
Anticipated Timeline for Mastery:
Generalization strategy:
Restrictive/Repetitive Patterns of Behavior (i.e. stereotyped/repetitive motor movements, insistence on sameness, inflexible
adherence to routines, highly fixated interests, hyper/hyporeactivity to sensory input):
Goal(s):
Baseline:
Intervention:
Anticipated Timeline for Mastery:
Generalization strategy:
Other treatment goals (if there are other treatment goals that are adaptive in nature, include relationship of autistic symptoms to
these goals):
Goal(s):
Baseline:
Intervention:
Anticipated Timeline for Mastery:
Generalization strategy:
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APPLIED BEHAVIOR ANALYSIS THERAPY
Individualized Treatment Plan – Initial Assessment
Parenting goals (include specific detailed description of interventions with parents including plan for transferring interventions
with the patient to parents):
Goal(s):
Baseline:
Intervention:
Anticipated Timeline for Mastery:
Specific strategies for coordination of care IEP/School:
Specific strategies for coordination of care with other current treatment programs (Speech, OT/PT, Medical, Mental
Health, Community):
How does ABA treatment not duplicate/overlap with school based or other treatment programs:
Any other relevant information regarding treatment plan:
Discharge Criteria: (specific behavioral goals that when reached indicate patient is ready for lower level of care and/or is not a
safety risk, able to adequately participate in home, school, or community activities):
Number of requested hours of service per month for:
Lead behavioral therapist:
Unlicensed provider:
Supervision of unlicensed provider:
Parent training:
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APPLIED BEHAVIOR ANALYSIS THERAPY
Individualized Treatment Plan – Initial Assessment
Group therapy:
Total number of hours requested:
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