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~~ About You ~~ |
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Name |
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Relationship
to Child |
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Phone |
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Email |
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~~
About the Child ~~ |
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Name |
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Parent(s)
Name(s) |
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Date
of Birth |
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School
District |
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Address |
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Diagnosis |
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Date
of Diagnosis |
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Clinic |
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Clinician |
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~~
Questions ~~ |
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What
is your understanding of Applied Behavioral
Analysis (ABA)? |
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What
do you see as your child’s greatest
strengths? |
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What
kind of things do you feel your child
needs the most work on at this time (behavior,
language, academics, play, social, etc.)? |
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When your child isn't actively engaged, what do they do typically? |
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What
are your short-term goals for your child
(3 months)? |
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What
are your one year goals for your child? |
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What services are currently in place? (ST, OT, school placement, ABA) |
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Have
you ever had a home program? If so, with
whom, for how long, and what is the purpose
of this evaluation? |
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If your child has had a home program before, describe some of the characteristics of prior therapists that you feel were well suited for your child. (Example: prior therapist had a mellow personality and naturally calmed my child.) |
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ABA
is a home-based intervention that requires
a high level of parent involvement to
be successful. Are you willing and able
to be an active participant in your child’s
treatment by following through with Consultant
developed behavior plans, parent homework,
etc.? |
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Is
the school district or regional center
funding the program? How many hours have
been approved? |
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Is
your child in school? What is the educational
placement (SDC, SH, MS, etc.)? Have you
seen the classroom and the other students?
Do you feel it is appropriate? |
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Specifically, what ELCA services do you feel would best fit yours and your child's needs (if known)? (Examples: ABA Home Program, School Aide Support, Social Skills Group, Parent Training, Consultation.) |
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What
other information do you feel would be
useful? |
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