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1 · Session Information

Client Name DOB Auth # CPT Code Session Date Start End Total Min Provider / RBT Cert # Insurance Name Insurance Member ID Modifier Location Select Location 02 – Telehealth Provided Other than in Patient’s Home 03 – School 10 – Telehealth Provided in Patient’s Home 11 – Office 12 – Home Appointment Type Select Type In-person Telehealth Indirect

People Present

Parent / Caregiver Supervisor BCBA Therapist Other

Other Person(s)

2 · Social Skills Group Details

Group size 2 Group size 3 Group size 4 Group size 5 Group size 6+

2 · Medical Necessity & Clinical Justification

Client demonstrates deficits in peer interaction / social reciprocity Client requires structured group to practice social skills Client unable to initiate or maintain age-appropriate peer conversations Client exhibits social avoidance, isolation, or refusal in group contexts Progress data supports continued group services at current level of care Social goals not yet mastered; generalization to natural settings ongoing

Other

3 · Social Skills Targets Addressed

Greetings / farewells Initiating conversation Maintaining topic Turn-taking in conversation Joining a group activity Sharing / cooperative play Perspective-taking / empathy Reading social cues Managing conflict / disagreement Asking for help appropriately Personal space & boundaries Sportsmanship / winning-losing Emotion identification Self-regulation in group Following group instructions Other

Other target

4 · Treatment Goals & Progress

Goal / Branch Name	Meas. Method	Data Point	Phase	% Correct	Mastery?	Initials	Notes
	Frequency Duration Time Sampling % Correct Task Analysis		Baseline Intervention Maintenance Generalization		Yes No Partial
	Frequency Duration Time Sampling % Correct Task Analysis		Baseline Intervention Maintenance Generalization		Yes No Partial
	Frequency Duration Time Sampling % Correct Task Analysis		Baseline Intervention Maintenance Generalization		Yes No Partial
	Frequency Duration Time Sampling % Correct Task Analysis		Baseline Intervention Maintenance Generalization		Yes No Partial

5 · Group Dynamics & Client Interaction

Engaged positively with peers throughout session Required redirection to maintain group participation Initiated interaction with at least one peer independently Responded to peer initiations with prompting Demonstrated target skill without prompting Exhibited interfering behavior — BIP strategies applied

6 · Reinforcement & Prompting

Continuous (CRF) Fixed Ratio (FR) Variable Ratio (VR) Group Contingency Token Economy Differential (DRO/DRA/DRI)

Reinforcer 1 Reinforcer 2 Reinforcer 3 Reinforcer 4 Reinforcer 5 Reinforcer 6

7 · Session Summary & Narrative

Group was structured; all clients participated in planned activities Group required additional behavioral management today Clients demonstrated generalization of skills across group members New skill or concept introduced; initial response was positive

Narrative

8 · Plans

Continue current group curriculum as written Advance client to next phase for mastered targets Modify group activity to increase peer interaction opportunities Adjust prompt level based on performance data New social skill target Increase natural environment / generalization activities

Other Recommendation

2 · Medical Necessity & Clinical Justification

Treatment plan requires modification based on data trends Client not responding to current intervention New problem behavior emerged requiring BIP updates Client met mastery criteria; new phase required Skill acquisition rate below expected Delivered training on newly introduced goals and corresponding intervention protocols Treatment plan review cycle due Supervision to monitor implementation of evidence-based interventions and treatments fidelity

Other

3 · Supervision Activities Conducted

Directly observed RBT implement treatment programs Modeled / demonstrated procedures Reviewed session data with supervisee Provided verbal/written feedback Scored competency on skill acquisition Scored competency on behavior reduction Reviewed ABC data / behavior logs Discussed ethical/professional conduct Completed competency assessment/review

4 · Protocol Modifications Made

Updated / added skill acquisition targets Modified reinforcement schedule/type Changed prompt level/fading procedure Introduced new program goals to address emerging skill deficits and increase independence Adjusted mastery criteria Modified data collection procedure Advanced to maintenance/generalization Discontinued program — mastery achieved Added new behavior reduction target Modified antecedent/environmental arrangement

Other Modification

5 · Goals Reviewed / Modified

Goal / Program Name	Current Data	Trend	Modification Made	Effective Date	BCBA Initials	Notes
		↑ Improving → Stable ↓ Declining Mastered Introduced Hold
		↑ Improving → Stable ↓ Declining Mastered Introduced Hold
		↑ Improving → Stable ↓ Declining Mastered Introduced Hold
		↑ Improving → Stable ↓ Declining Mastered Introduced Hold

6 · RBT / Supervisee Performance Feedback

Implemented programs with fidelity (80%+) Required correction/re-training Data collected accurately/consistently Demonstrated professional and ethical conduct Communicated effectively with caregiver Additional training assigned

Feedback Provided

7 · Session Summary & Clinical Narrative

Client responded positively; No modifications needed Monitored Childs response to behavioral interventions via direct observation Safety/crisis concern addressed

During this session, BCBA observed

8 · Plan & Recommendations

Continue current programs with modifications Schedule follow-up supervision Reassess acquisition progress at next observation Provide additional RBT training Update plan and review with caregiver acknowledgment Submit updated plan to payer Increase supervision frequency Begin discharge / step-down planning

Other

2 · Family Training Details

Client present: participated Client present: observing only No: caregiver training only

3 · Medical Necessity & Clinical Justification

Caregiver unable to implement supports independently Safety concerns in home environment Training needed for generalization Treatment plan has caregiver goals- requiring training Problem behavior increased outside sessions New skills need caregiver support Booster/updated training required Family system change requires updates

Other

3 · Training Topics Covered

Overview/review of treatment goals Behavior function & ABC model Antecedent strategies/prevention Reinforcement principles Prompting procedures/fading Data collection/recording Extinction/planned ignoring Response blocking/redirection NET DTT Generalization strategies Crisis/safety procedures Token economy/behavior momentum Schedule/routine modifications Other

4 · Training Methods Used

Verbal instruction/explanation Written materials/handout Video model reviewed Live demonstration by BCBA Caregiver practiced with client Role play/rehearsal Q&A/discussion

5 · Caregiver Performance & Response

Demonstrated understanding of concepts Required additional modeling/re-explanation Independently implemented strategy with client Implemented with BCBA verbal prompting Asked questions and received answers Expressed concerns Demonstrated 80%+ accuracy Follow-up training needed

Caregiver Concerns / Notes

6 · Client Goals Addressed in Training

Goal / Program	Training Focus	Caregiver Accuracy	Barrier	BCBA Initials	Notes
		80%+ Independent 60–79% w/ prompts Below 60% N/A – observation only
		80%+ Independent 60–79% w/ prompts Below 60% N/A – observation only
		80%+ Independent 60–79% w/ prompts Below 60% N/A – observation only
		80%+ Independent 60–79% w/ prompts Below 60% N/A – observation only

7 · Session Summary & Clinical Narrative

Caregiver engaged and motivated Caregiver required frequent modeling and prompting support New content introduced Caregiver implemented program with child present Generalized to natural routine Environmental barrier identified

Today's training focused on Caregiver demonstrated Barrier towards Implementation outside of session

8 · Plan & Recommendations

Continue caregiver training Assign home practice task Advance to next training topic Review home data at next session Increase training frequency Coordinate with RBT Update plan with new caregiver targets Begin fading BCBA support Schedule reassessment Refer to support resources

Other

2 · Medical Necessity & Clinical Justification

Client exhibits skill deficits in communication requiring structured ABA Client requires 1:1 behavioral support to access reduction of behavioral barriers to learning Progress data supports continued services at current level of care Client responded to intervention; needed to maintain gains Client demonstrates problem behavior posing risk to self, others, or learning Caregiver to implement behavior plan with direct therapist modeling support Treatment goals mastered; fading / generalization / maintenance phase New skill targets added per BCBA analysis; treatment plan updated Other:

3 · Barriers to Progress

Elopement Property Destruction Tantrum / Crying Verbal Aggression Protest / Non-Compliance Self-Injurious Behavior (SIB) Interfering Stereotypy Physical Aggression Pica Inappropriate Vocalizations Refusal / Avoidance Other:

4 · Treatment Goals & Progress

Goal / Data Summary

5 · Reinforcement Used

Continuous (CRF) Fixed Ratio Variable Ratio Fixed Interval Variable Interval Differential Reinforcement

Reinforcers Used

6 · Prompt Hierarchy Used

Full Physical Partial Physical Model Gestural Visual / Pictorial Vocal / Verbal Textual Independent Error Correction Errorless Teaching Time Delay Most-to-Least Least-to-Most

7 · Caregiver Participation & Training

Active – participated in trials Observing only Demonstrated / practiced DTT or NET procedures Questions noted – follow up

8 · Session Summary & Clinical Narrative

Client was cooperative and engaged throughout the session Client required frequent prompting to remain on task Client demonstrated progress toward treatment goals Problem behavior interfered; BIP strategies were implemented Reinforcement was effective in maintaining motivation

Session shortened / modified due to:

Narrative

9 · Plan & Recommendations

Continue current programs as written; no modifications needed Advance to next phase / level for mastered targets Modify reinforcement schedule based on session data Adjust prompt level based on performance trends Add new skill acquisition targets per BCBA direction Implement / update behavior intervention plan strategy Increase caregiver training focus next session Consult BCBA re: progress plateau, regression, or crisis Coordinate with school / other providers for generalization Initiate discharge planning; goals approaching mastery

Other Recommendation