SELF-CHECK YOUR INTAKE REPORT Section One (initial report components, 34 in total) Identifying Information (12 components) ● Client’s name ● Birth date ● Age ● Gender ● Caregivers’ names ● Phone number ● Email ● Address ● Funding ● Current diagnosis ● Date of assessment ● Behavior analyst’s name Referral Information (3 components) ● Entity requesting the referral provided. ● Overall reason for referral provided. ● Stated the targeted behaviors necessitating the referral in observable and measurable terms. Description of the Indirect Assessment Process (3 components) ● Dates and locations of interviews and/or observations included. ● Stated person interviewed and their relationship to the client. ● Stated tools used during the interview. Background Information (13 components) ● It is made clear that the information was not directly assessed, but based on caregiver report. ● A general statement on the client’s strengths and deficits provided. ● Description of the client’s communication (speaker and listener) skills provided. ● Description of the client’s self-help/adaptive skills provided. ● Description of the client’s motor skills provided. ● Description of the client’s academic skills provided. ● Description of the client’s play skills provided. ● Description of the client’s social skills provided. ● Living situation/family history described. ● School/day program placement and history described. ● Medical history described. ● Language and culture described. ● Previous and/or concurrent interventions described, or stated that none were provided. Preferences (3 components) ● It is made clear that the information was not directly assessed, but based on caregiver report. ● The method for collecting the information from the caregiver is made clear (e.g., questionnaire, interview). ● Potential reinforcers are listed. Section Two (challenging behavior report components, 28 in total) Functional Assessment for Behavior One (14 components) ● Stated functional assessment tool(s) used. ● Named an observable and measurable behavior. ● Operational definition of the behavior is clear, concise, and in-line with ABA terminology. ● Information on the length of time that the behavior has been happening (e.g., a week, a month, etc..) is provided. ● Information on historical changes in the severity of the behavior is provided (e.g., used to happen more or less, has become more intense, etc..). ● Quantitative baseline data included. ● Graph of the baseline data included. ● Stated antecedents likely to trigger/precede problem behavior. ● The stated antecedents are not the behavior of the client. ● The stated antecedents are observable and measurable. ● Stated the consequences likely to support/follow the problem behavior. ● The stated consequences are not the behavior of the client. ● The stated consequences are observable and measurable (unless specific to behaviors maintained by automatic reinforcement, in which case the behavior should be described as a change within the skin). ● Stated the hypothesized function the behavior serves for the client. Functional Assessment for Behavior Two (14 components) ● Stated functional assessment tool(s) used. ● Named an observable and measurable behavior. ● Operational definition of the behavior is clear, concise, and in-line with ABA terminology. ● Information on the length of time that the behavior has been happening (e.g., a week, a month, etc..) is provided. ● Information on historical changes in the severity of the behavior is provided (e.g., used to happen more or less, has become more intense, etc..). ● Quantitative baseline data included. ● Graph of the baseline data included. ● Stated antecedents likely to trigger/precede problem behavior. ● The stated antecedents are not the behavior of the client. ● The stated antecedents are observable and measurable. ● Stated the consequences likely to support/follow the problem behavior. ● The stated consequences are not the behavior of the client. ● The stated consequences are observable and measurable (unless specific to behaviors maintained by automatic reinforcement, in which case the behavior should be described as a change within the skin). ● Stated the hypothesized function the behavior serves for the client. Section Three (intervention planning/program development components, 30 in total) Intervention Strategies for Behavior One (11 components) ● Named at least one ABA-based antecedent strategy. ● Described at least one ABA-based antecedent strategy in technological detail. ● Named at least one ABA-based consequence strategy. ● Described at least one ABA-based consequence strategy in technological detail. ● Named one functionally equivalent replacement behavior. ● Included one goal related to decreasing the challenging behavior or increasing the functionally equivalent replacement behavior. ● The included goal states the behavior targeted for change (increase or decrease). ● The included goal states the criteria for change. ● The included goal is reasonable in regard to the baseline data presented on the targeted behavior or objectives are included to break down the goal into needed successive approximations. ● A plan for ongoing data collection and analysis specific to the target behavior is included. ● A brief sentence or two about the plan for generalization or maintenance is included. Intervention Strategies for Behavior Two (11 components) ● Named at least one ABA-based antecedent strategy. ● Described at least one ABA-based antecedent strategy in technological detail. ● Named at least one ABA-based consequence strategy. ● Described at least one ABA-based consequence strategy in technological detail. ● Named one functionally equivalent replacement behavior. ● Included one goal related to decreasing the challenging behavior or increasing the functionally equivalent replacement behavior. ● The included goal states the behavior targeted for change (increase or decrease). ● The included goal states the criteria for change. ● The included goal is reasonable in regard to the baseline data presented on the targeted behavior or objectives are included to break down the goal into needed successive approximations. ● A plan for ongoing data collection and analysis specific to the target behavior is included. ● A brief sentence or two about the plan for generalization or maintenance is included. Additional Skill Acquisition Targets (8 components) ● Description of procedures for assessing skills (e.g., assessment tool used, number of assessment sessions, assessment location) is included, or a statement as to why skills were not assessed. ● Baseline data are referenced (do not need to be fully provided), or the lack of baseline data are explained. ● Skill acquisition goals which support this client’s reason for referral are included. ● All skill acquisition goals state the antecedent condition (e.g., when presented with). ● All skill acquisition goals state the behavior targeted for change (increase or decrease). ● All skill acquisition goals state the criteria for change. ● A general plan for ongoing data collection and analysis for all skill acquisition goals is included. ● A general plan for generalization/maintenance of all skill acquisition goals is included. Section Four (caregiver support components, 20 in total) Basic Caregiver Training Plan (5 components) ● Includes a few sentences about the general plan for caregiver training (e.g., who, where, when, how). ● It is made clear that multiple caregivers were recruited to participate in the training; therefore including multiple caregivers in the training plan or a reason why only one caregiver was targeted. ● States the expected level of caregiver participation (e.g., sessions, workshops, etc..). ● Outlines the general time commitment expected of caregivers. ● Mentions the use of specific goals and training procedures. Baseline Data (2 components) ● Includes baseline data, which can be quantitative (e.g., based on probes of caregiver goals) or qualitative (e.g., based on observations and/or caregiver reports) which demonstrate a rationale for caregiver training. ● The data/rationale for training include positive and negative aspects of the caregiver(s) behavior. Caregiver Support Goals (13 components) ● At least two caregiver support goals are included. ● For caregiver goal number one: it aligns with the challenging behavior and/or skill acquisition goals. ● For caregiver goal number one: it clearly supports the client’s reason for referral. ● For caregiver goal number one: it clearly states the antecedent condition (e.g., when presented with). ● For caregiver goal number one: it clearly states the behavior targeted for change (increase or decrease). ● For caregiver goal number one: it clearly states the criteria for change. ● For caregiver goal number one: it clearly states a plan for ongoing data collection and analysis. ● For caregiver goal number two: it aligns with the challenging behavior and/or skill acquisition goals. ● For caregiver goal number two: it clearly supports the client’s reason for referral. ● For caregiver goal number two: it clearly states the antecedent condition (e.g., when presented with). ● For caregiver goal number two: it clearly states the behavior targeted for change (increase or decrease). ● For caregiver goal number two: it clearly states the criteria for change. ● For caregiver goal number two: it clearly states a plan for ongoing data collection and analysis. Total number of points: