Preliminary Assessment Questionnaire

Recipient – Preliminary Assessment Questionnaire

Your Child information

Does your child attend to an especial program at school (IEP)

Yes

Recipient – Preliminary Assessment Questionnaire

Mother information

Recipient – Preliminary Assessment Questionnaire

Additional

Recipient – Preliminary Assessment Questionnaire

Background Information

Do you have a diagnosis and assessment completed by a Developmental Pediatrician, Psychologist, Neurologist, or Psychiatrist?

Yes

NoDo you have an ABA Referral?

Yes

Recipient – Preliminary Assessment Questionnaire

Child’s Diagnosis

What is your child’s Diagnosis?

Autism Spectrum Disorder (F84.0)

Attention deficit and Hyperactive Disorder

Other

Recipient – Preliminary Assessment Questionnaire

Your Child’s Behaviors

Which are the problem behaviors the child exhibit?

Tantrum

Non-Compliance

Aggressive behaviors

Refusals

Property destruction

Self-Injury

Sleep time problem behaviors

Mealtime problem behaviors

Repetitive behavior

Other

Recipient – Preliminary Assessment Questionnaire

Your Child’s Verbal Abilities

How would you describe your child’s verbal abilities?

Non-Verbal (does not use words or signs to express wants or needs)

Verbal (uses words or signs to express wants or needs)

High Verbal (uses sentences to communicate, engages in conversation)

Recipient – Preliminary Assessment Questionnaire

Your Child’s Problem

Overall, your child problem behaviors are

Severe (high frequency of concerning behavior, hitting, biting, destruction)

Mild/Moderate (such as crying, whining, tantrums, few disruptive)

Compliant (Does not engage in concerning behaviors)

Recipient – Preliminary Assessment Questionnaire

ABA therapy

Did the child have ABA therapy before us?

Yes

NoDo you have a copy of the BIP of the other provider?

Yes

Recipient – Preliminary Assessment Questionnaire

Your Child’s Schedule

How is your child current schedule?

Recipient – Preliminary Assessment Questionnaire

Other Therapeutic Services

Is Your child is taking other therapies?

Speech (SLP)

OT (Occupational Therapy)

PT (Physical therapy)

Feeding

Other

Recipient – Preliminary Assessment Questionnaire

Your Child’s Availability

What is the availability to work with your child? At what time?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Recipient – Preliminary Assessment Questionnaire

Additional Questions

A BH Field’s representative will reach out to you shortly. Before starting the process, BH Field need you sign the consents to request the authorization to the health insurance. After speaking with the BH Field’s representative, we will send you via email the documents to be signed. As soon as you have it as soon as we can start the process. You should have ready the following documents:

Diagnosis and assessment report completed by a Developmental Pediatrician, Psychologist, Neurologist, or Psychiatrist.
Prescription or Referral to ABA therapy
Insurance card of the recipient
Certification of Birth of the recipient
Driver License of the Parent or Legal Guardian
Report of other therapies your child attend (Speech, OT, PT, Feeding…)
IEP report
Assessment from the previous ABA Provider

Recipient – Preliminary Assessment Questionnaire

Your Child information

Recipient – Preliminary Assessment Questionnaire

Mother information

Recipient – Preliminary Assessment Questionnaire

Additional

Recipient – Preliminary Assessment Questionnaire

Background Information

Recipient – Preliminary Assessment Questionnaire

Child’s Diagnosis

Recipient – Preliminary Assessment Questionnaire

Your Child’s Behaviors

Recipient – Preliminary Assessment Questionnaire

Your Child’s Verbal Abilities

Recipient – Preliminary Assessment Questionnaire

Your Child’s Problem

Recipient – Preliminary Assessment Questionnaire

ABA therapy

Recipient – Preliminary Assessment Questionnaire

Your Child’s Schedule

Recipient – Preliminary Assessment Questionnaire

Other Therapeutic Services

Recipient – Preliminary Assessment Questionnaire

Your Child’s Availability

Recipient – Preliminary Assessment Questionnaire

Additional Questions

Thank you