Pre-Screen Form prior to ABA Assessment

This is a form I use as a guide before I assess the child.  I usually call the parent and discuss these point.  Or if time is a limiting factor, I will send it to the parent and ask them to fill it out.  I hope you can use it to drive your assessments.  This is not comprehensive, it is a screening tool to better prepare you for the initial assessment. 

Pre-Assessment Screening Form  

Medical History:

Current Medical Concerns:   
Medications:

Other Therapies: ◻ PT   ◻ OT  ◻ Speech Language  ◻ Other________

Strengths: List and describe skills and behaviors that appropriate and functional for the client.
Note perceived function of behavior ◻ Attention ◻ Escape ◻ Access to Tangible ◻ Automatic Reinforcement
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Interfering Behaviors: List and describe priority problem behaviors.
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Reinforcers: Activities, objects, people, foods, situations, games that are preferred.
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Communication Skills: Primary method of communication:
◻ Picture Communication ◻Sign Language ◻ACC ◻ Verbal ◻Gestures 

Barriers to Communication:
◻Impaired Articulation ◻Impaired Mand ◻Impaired Tact ◻Echoic ◻ Scrolling ◻ Impaired Echoic ◻ Impaired Intraverbal◻Prompt Dependent ◻Weak Speaker Skills ◻Weak Listener Skills ◻Weak Interpretation of Non-Verbal Communication 

Variables that may contribute to aversive behaviors & impede learning:
◻ Auditory Noise ◻ Visual Distractions ◻ Environment ◻ Time ◻ Crowds ◻ Proximity to others ◻ Transitions ◻ Limited MO’s ◻ Failure to Generalize ◻ Negative Behaviors 
◻ Lack of Instructional Control ◻ Impaired Motor Imitation ◻ Sensory Defensive   
◻ Impaired Visual Perceptual Skills ◻ Impaired Social Skills ◻ Prompt Dependent 
◻ Impaired Scanning ◻ Impaired Attending      ◻ Reinforcement Dependent ◻ Self Stimulation ◻ Obsessive-Compulsive Behaviors ◻ Hyperactive Behaviors 

Adaptive Living Concerns: ◻ Toileting ◻ Eating ◻ Dressing ◻ Indep. Play ◻ Social Play ◻ Group Skills ◻ Fine Motor ◻ Gross Motor ◻ Household Routines ◻ Bathing ◻ Tooth brushing ◻ Hair ◻ Cleaning ◻ Cooking ◻ Leisure Time

References: VB-MAPP M. Sundberg, Conducting School-Based Functional Behavioral Assessment M. Steege & T.S. Watson