"Applied Behavioral Support Services Assessment Form" - Delaware

Applied Behavioral Support Services Assessment Form is a legal document that was released by the Delaware Department of Labor - a government authority operating within Delaware.

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Supported Employment Assessment Addendum
Department of Labor
DIVISION OF VOCATIONAL REHABILITATION
APPLIED BEHAVIORAL SUPPORT SERVICES
ASSESSMENT
(Must Accompany DVR - 7 Authorization in Order to Receive Payment)
DOB:
Name of Consumer:
Evaluator:
DVR Counselor:
Dates:
Times:
Total Hours Spent With Consumer:
REASON FOR REFERRAL:
The Specific questions to be addressed are:
1.
2.
3.
PROCEDURES USED:
GENERAL BEHAVIORS OF CONCERN:
In general, the consumer exhibits problems with:
1.
2.
3.
OPERATIONAL DESCRIPTION OF PROBLEM BEHAVIORS: (Consider emotional difficulties, motivation,
impulsivity, distractibility, obsessive compulsive behaviors, anxiety, and social interactions)
1.
Page 1 of 5
Supported Employment Assessment Addendum
Department of Labor
DIVISION OF VOCATIONAL REHABILITATION
APPLIED BEHAVIORAL SUPPORT SERVICES
ASSESSMENT
(Must Accompany DVR - 7 Authorization in Order to Receive Payment)
DOB:
Name of Consumer:
Evaluator:
DVR Counselor:
Dates:
Times:
Total Hours Spent With Consumer:
REASON FOR REFERRAL:
The Specific questions to be addressed are:
1.
2.
3.
PROCEDURES USED:
GENERAL BEHAVIORS OF CONCERN:
In general, the consumer exhibits problems with:
1.
2.
3.
OPERATIONAL DESCRIPTION OF PROBLEM BEHAVIORS: (Consider emotional difficulties, motivation,
impulsivity, distractibility, obsessive compulsive behaviors, anxiety, and social interactions)
1.
Page 1 of 5
2.
3.
HYPOTHYSIS OF FUNCTIONS OF PROBLEM BEHAVIORS:
1.
2.
3.
SETTINGS, SITUATIONS IN WHICH PROBLEM BEHAVIOR IS MOST LIKELY TO OCCUR:
Page 2 of 5
FUNCTIONAL INFORMATION ABOUT SENSORY REGULATION:
GENERAL PREVENTION STRATEGIES:
ENVIRONMENTAL STRUCTURE AND SUPPORTS NEEDED:
BEHAVIORAL SUPPORTS CONSUMER WILL NEED TO FUNCTION EFFECTIVELY AT WORK:
Page 3 of 5
RESPONSE TO PROBLEMATIC BEHAVIORS:
SKILLS THAT NEED TO BE TAUGHT AND SOME STRATEGIES FOR DOING SO:
CONCLUSIONS:
Conclusions are summarized through answers to the Vocational Counselor's questions below:
1.
2.
Page 4 of 5
3.
OTHER RECOMMENDATIONS:
Date:
Submitted By:
Page 5 of 5