Client Name: ZZZTest myBrightlink PROD Test

Client Scheduling ZZZTESTING

MRN: number
Date of Report: 11/07/2021
Transfer Report

Transfer Report

Client Information
Service Type 3-Tier ABA
Caregiver Training
Group ABA
Parent Led ABA
Social Skills Group
Service Delivery Method In-Person
Telehealth
Client Full Legal Name ZZZTest myBrightlink PROD Test Client Scheduling ZZZTESTING
Medical Record Number number
Date of Birth 09/04/2018
Client Age 3Y
Date of Report 11/07/2021
Parent(s)/Guardian(s) hung partet
Address Not Available

Not Available, Not Available 94567

Out of (Funder) Service Area test
(OOSA)
Phone Number 0353116891
Treatment Team werewr
Diagnosis Diagnosis
Date of Diagnosis 11/02/2021
Diagnosing MD or dad
Psychologist
Initial BHT Start Date 11/01/2021

Academic Performance (School)

IEP No
Special Education / SDC No
Performance in General Medium
Education

Page 1 of 25
 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

Recommendations
Service Recommendation
Based on the information collected during re-assessment, observation, and Client's learner profile,
Easterseals Northern California has determined that intensive ABA services are / are not
appropriate at this time. Direct services should be composed of home, clinic, and/or telehealth-
based services focused on skill acquisition as detailed in the report below. Additionally, natural
settings in Client's community should also be incorporated regularly into the intervention services
provided in order to generalize their skills. The following recommendations are being made
regarding these services.

It is recommended that Client receive / not receive ongoing intensive behavioral intervention.

Intervention should consist of:

___________ Recommended Hours of direct service (H2019) per week. (Optimal Hours clinically
recommended for treatment)

___________ Requested Hours of direct service (H2019) per week for new authorization period.
(Beneficial Hours accepted by the family. Treatment plan should be based on Beneficial Hours)

*Please include explanation of difference between requested and recommended hours if applicable

Authorization Request
Practitioner Level Hours Location of services
Direct Level Practitioner 4 direct hours per week 44
- H2019
Group ABA - H2014 4 direct hours per week 44
Social Skills Group - 4 direct hours per week 444
H2014,HQ
Mid-Level Supervisor - 4 direct and indirect hours 444
H0032 per month
High-Level Supervisor - 4 direct and indirect hours 444
H0004 per month

Recommendation Rationale:
sadqd

Page 2 of 25
 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

Are in-person services recommended?

Yes

Are telehealth services recommended?

Yes
Parent or caregiver and client (if appropriate) has given verbal agreement to treatment by telehealth

Are center-based ABA and/or group services recommended?

No

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 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

Transfer Summary
Treatment Summary
Current treatment authorization ewr
dates

Current Authorization
Direct Service Practitioner - 4 hours per week 4
H2019
Group ABA - H2014 4 hours per week 4
Social Skills Group - H2014,HQ 3 hours per week 4
Mid-Level Supervisor - H0032 4 hours per month 4
High-Level Supervisor - H0004 4 hours per month 4

Average Hours provided this authorization period

Direct Service Practitioner - 04 hours per week 4
H2019
Group ABA - H2014 4 hours per week 4
Social Skills Group - H2014,HQ 4 hours per week 4
Mid-Level Supervisor - H0032 4 hours per month 4
High-Level Supervisor - H0004 4 hours per month 4

Service Delivery
Scheduling and client/family attendance in the preceding treatment period:
QWEQWE
Cultural and/or environmental considerations relevant for treatment planning, if any:
QWEWQE
Issues related to service delivery, if any:
QWEWQE

Transfer Summary
Initiation of transfer
QWEWQE
Reasons for transfer
WQEQWEWE

Page 4 of 25
 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

Date services ended with current provider

QWEWQE
Overlap and collaboration with new provider
QWEQEQ
Family and client support for transfer
QWEQWER

Page 5 of 25
 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

Reassessment
Reassessment is a core part of the review of progress in the preceding treatment period, and development
of the proposed treatment plan and recommendations for treatment.
Vineland Adaptive Behavior Scales - Third Edition Parent/Caregiver Interview
Easterseals Northern California uses the Vineland Adaptive Scales, 3rd edition to assess an individual’s
adaptive behavior functioning. The standard scores reported have an average of 100 and a standard
deviation of 15. Age-equivalents indicate the average age of the individual from the Vineland-3 normative
sample who obtained the same raw score as the individual currently being assessed. Adaptive levels are
scored on a 5-point scale from Low to High.
Vineland-3 completed by WAEWQE
Respondent QWEQWE
Date completed 11/07/2021
Score summary
Domain Standard Score Adaptive Level Percentile Rank
Communication WEQWE QWEWQE QWEWE
Daily Living Skills QWEWQE QWEWQE QWEWQE
Socialization QWEQWE QWEWQEQWE QWE
Motor Skills WQEWQE QWEWQE QWE
Adaptive Behavior Composite QWE QWEWQE QWE

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 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

Domain details
Domain/Subdomain Content v-Scale Score Age Equivalent Adaptive Level
(Years: Months)
Communication
Receptive Listening, paying QWE QWR QWR
attention, and
understanding
others
Expressive Language QWR QWR QRW
complexity; use of
language to
communicate with
others
Written Basic academics; QWR QWR QWR
reading and writing
skills used in daily
tasks
Daily Living Skills
Personal Self-care skills, QWR QWR QWR
personal hygiene,
manners
Domestic Helping with QWR QWR QWR
chores & family
routines
Community Use of time, QWR QWR QWR
money, telephone,
computer & school
or job skills
Socialization
Interpersonal Social imitation; QRWQR QR QR
Relationships forming friendships
with others;
cooperation &
sharing

Page 7 of 25
 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

Play and Leisure Play or creative QWRWQR WQR QRW

Time abilities & use of
leisure time
Coping Skills Demonstrating QWR QWR QR
responsibility &
sensitivity to
others
Motor Skills
(optional)
Gross Motor Use of larger
muscle groups
Fine Motor Use of smaller
muscle groups

Domain/Subdomain v-Scale Score Level

Maladaptive Behavior Index
(optional)
Internalizing
Externalizing
Other

Vineland-3 summary of results

Client name’s overall score of _____ on the Adaptive Behavior Composite Scale fell in the _____ range
when compared with individuals the same age. This score is derived from the following three/four domains:
Communication, Daily Living Skills, Socialization, and Motor Skills. Client name’s _____ reported areas of
strength in the _____ domains, and reported relative areas of weakness in the _____ domains. Specific
concerns include _____. The Maladaptive Behavior Index fell in the _____ range and indicates Client
name _____ displaying _____ maladaptive behavior at home.

Page 8 of 25
 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

Treatment Plan
Below is the treatment plan for intervention and provider’s report on progress toward goal mastery.
Treatment plans are based on ongoing assessment, response to treatment, priorities of the individual, and
input from any other professionals that support the family.

Receptive Communication
Skills in this domain target a client’s responses to communication from others, across settings,
communication partners, and language functions.

1. New
Goal Long Description

Assessment Tool Source Long Description

Mastery Criteria hung

Generalization Criteria GENERALIZATION_CRITERIA
Initial Baseline / Date BASELINE
Introduced
Progress Reporting WQEQWE

Graphic Display

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 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

2. New
Goal Long Description
Assessment Tool Source Assessment Tool Source
Mastery Criteria Mastery Criteria
Generalization Criteria GENERALIZATION_CRITERIA
Initial Baseline / Date BASELINE
Introduced
Progress Reporting QWEWQE

Graphic Display

3. New
Goal Graduated Target: Clean House : Steps
Assessment Tool Source dog and cat assessment
Mastery Criteria 1
Generalization Criteria GENERALIZATION_CRITERIA
Initial Baseline / Date BASELINE
Introduced
Progress Reporting QWEQWE

Expressive Communication
Skills in this domain target a client’s functional use of expressive language, across settings,
communication partners, and language functions.

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 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

Pragmatic Communication
Skills in this domain target a client’s functional use of communication, imitation, and joint attention in
interactions with others and in social environments.

Self Help and Daily Living Skills

Skills in this domain focus on activities of daily living, including developmentally appropriate personal
independence (eating, dressing, hygiene, household responsibilities), safety, play and leisure
(independent and with adult and peer partners), and community skills.

4. New
Goal 9/9 : Naturalistic Teaching : Maintenance
Assessment Tool Source dog and cat
Mastery Criteria hung test 9/9
Generalization Criteria GENERALIZATION_CRITERIA
Initial Baseline / Date BASELINE
Introduced
Progress Reporting WQEQWE

Graphic Display

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 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

5. New
Goal Long Description

Assessment Tool Source Assessment Tool Source

Mastery Criteria Mastery Criteria
Generalization Criteria GENERALIZATION_CRITERIA
Initial Baseline / Date BASELINE
Introduced
Progress Reporting QWEQWE

Graphic Display

Behavior
This domain focuses on behavioral excesses and skill deficits which pose a risk to the client or others, or
present a clinically significant need for intervention.
Crisis Plan
In the event of an unexpected crisis during session via in person or over Telehealth, treatment staff will
follow the general guidelines outlined:
Responsible Adult oversees client safety during session and is available/accessible during both in
person and/or Telehealth sessions
Treatment staff will ensure safety of self
If the Responsible Adult is unavailable or unable to help, treatment staff will assist by calling 911 if
appropriate and possible (note: during Telehealth sessions parent should be available/accessible
at all times)
Treatment staff will inform supervisor of the incident as soon as possible
Immediate notification to the BHPN and submission of a Reportable Event Form to
[email protected] within 1 business day of the incident

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 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

The most recent behavior reduction goal(s) and Behavior Intervention Plan(s) are included below.
Is physical intervention clinically indicated?
No
If physical intervention is clinically indicated, has the intervention in this treatment plan been reviewed
and approved by the BHPN?
No
Has the intervention been reviewed with parent/caregiver/client and are they in agreement with the
described intervention?
No

6. New
Goal Long Description
Source Source
Mastery Criteria Mastery Criteria
Operational Definition Operational Definition
Initial Baseline / Date 5
Introduced
Progress Reporting QWEWQEWQE

Graphic Display

Target Behavior 6 Count: Angry $#!#!#!$!$!$

Page 13 of 25
 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

Operational Definition: Operational Definition

(Precise definition of the target
behavior that includes what it
looks like, the beginning and end
of an incident or episode of the
behavior, and any exceptions)
Hypothesized Function Attention Seeking Escape or avoidance
(What keeps the behavior Access Automatic reinforcement
occurring over time)
Antecedent Manipulations Procedures and how to implement
(Preventative Strategies) Antecedent Modifications
Replacement Behavior(s) Functionally Equivalent Replacement Behavior(s):
(Behaviors that will occur instead List behaviors which serve the same function and are being
of the target behavior) recommended to replace the challenging behavior.
Incompatible Behavior(s):
Incompatible Behavior(s):
Other Alternative Behavior(s):
Other Alternative Behavior(s):
Consequence Manipulations Procedures and how to implement
(Reactive Strategies) Consequence Manipulations

7. New
Goal reduction`
Source source
Mastery Criteria hey
Operational Definition Operational Definition
Initial Baseline / Date 11
Introduced
Progress Reporting WQEQWEWQ

Graphic Display

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 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

Target Behavior 7 Cry out loud

Operational Definition: Operational Definition
(Precise definition of the target
behavior that includes what it
looks like, the beginning and end
of an incident or episode of the
behavior, and any exceptions)
Hypothesized Function Attention Seeking Escape or avoidance
(What keeps the behavior Access Automatic reinforcement
occurring over time)
Antecedent Manipulations Procedures and how to implement
(Preventative Strategies) Antecedent Modifications
Replacement Behavior(s) Functionally Equivalent Replacement Behavior(s):
(Behaviors that will occur instead Replacement Behavior(s)
of the target behavior) Incompatible Behavior(s):
Incompatible Behavior(s):
Other Alternative Behavior(s):
Other Alternative Behavior(s):
Consequence Manipulations Procedures and how to implement
(Reactive Strategies) Consequence Manipulations

Page 15 of 25
 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

8. New
Goal Long Description
Source Source
Mastery Criteria dwqdwqd
Operational Definition Operational Definition
Initial Baseline / Date dqwqwdwqd
Introduced
Progress Reporting QWEQWE

Graphic Display

Target Behavior 8 Fighting @!#!$!$!%I!%(! &!$ &!&%!&%!

Operational Definition: Operational Definition
(Precise definition of the target
behavior that includes what it
looks like, the beginning and end
of an incident or episode of the
behavior, and any exceptions)
Hypothesized Function Attention Seeking Escape or avoidance
(What keeps the behavior Access Automatic reinforcement
occurring over time)
Antecedent Manipulations Procedures and how to implement
(Preventative Strategies) Procedures and how to implement

Page 16 of 25
 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

Replacement Behavior(s) Functionally Equivalent Replacement Behavior(s):

(Behaviors that will occur instead Functionally Equivalent Replacement Behavior(s)
of the target behavior) Incompatible Behavior(s):
Incompatible Behavior(s):
Other Alternative Behavior(s):
Other Alternative Behavior(s):
Consequence Manipulations Procedures and how to implement
(Reactive Strategies) Procedures and how to implement

9. New
Goal count
Source something
Mastery Criteria dog and cat
Operational Definition something
Initial Baseline / Date 1
Introduced
Progress Reporting QWEQWE

Graphic Display

Target Behavior 9 New count 8 Sep

Operational Definition: something
(Precise definition of the target
behavior that includes what it
looks like, the beginning and end
of an incident or episode of the
behavior, and any exceptions)

Page 17 of 25
 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

Hypothesized Function Attention Seeking Escape or avoidance

(What keeps the behavior Access Automatic reinforcement
occurring over time)
Antecedent Manipulations Procedures and how to implement
(Preventative Strategies) hello
Replacement Behavior(s) Functionally Equivalent Replacement Behavior(s):
(Behaviors that will occur instead hello
of the target behavior) Incompatible Behavior(s):
hello
Other Alternative Behavior(s):
lllll alo
Consequence Manipulations Procedures and how to implement
(Reactive Strategies) hello

10. New
Goal New target 9/9: Duration
Source dog and cat
Mastery Criteria 1
Operational Definition Hung 9/9
Initial Baseline / Date 1
Introduced
Progress Reporting QWEQWE

Graphic Display

Target Behavior 10 New target 9/9: Duration

Page 18 of 25
 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

Operational Definition: Hung 9/9

(Precise definition of the target
behavior that includes what it
looks like, the beginning and end
of an incident or episode of the
behavior, and any exceptions)
Hypothesized Function Attention Seeking Escape or avoidance
(What keeps the behavior Access Automatic reinforcement
occurring over time)
Antecedent Manipulations Procedures and how to implement
(Preventative Strategies) Hung 9/9
Replacement Behavior(s) Functionally Equivalent Replacement Behavior(s):
(Behaviors that will occur instead Hung 9/9
of the target behavior) Incompatible Behavior(s):
Hung 9/9
Other Alternative Behavior(s):
Hung 9/9
Consequence Manipulations Procedures and how to implement
(Reactive Strategies) Hung 9/9

11. New
Goal Smoke 0809
Source Smoke 0809
Mastery Criteria Mastery Criteria Smoke 0809
Operational Definition Smoke 0809
Initial Baseline / Date Baseline Smoke 0809
Introduced
Progress Reporting QWEQWE

Graphic Display

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 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

Target Behavior 11 Smoke 0809

Operational Definition: Smoke 0809
(Precise definition of the target
behavior that includes what it
looks like, the beginning and end
of an incident or episode of the
behavior, and any exceptions)
Hypothesized Function Attention Seeking Escape or avoidance
(What keeps the behavior Access Automatic reinforcement
occurring over time)
Antecedent Manipulations Procedures and how to implement
(Preventative Strategies) Smoke 0809
Replacement Behavior(s) Functionally Equivalent Replacement Behavior(s):
(Behaviors that will occur instead Smoke 0809
of the target behavior) Incompatible Behavior(s):
Smoke 0809
Other Alternative Behavior(s):
Smoke 0809
Consequence Manipulations Procedures and how to implement
(Reactive Strategies) Smoke 0809

Caregiver Training
This domain is focused on education for caregivers. Goals are developed in collaboration with the
caregivers and reflect their identified needs and priorities.

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 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

12. New
Goal Training for parent of child 1
Source Dog, cat, WIKI
Mastery Criteria 1
Initial Baseline / Date BASELINE
Introduced
Progress Reporting QWEQWE

Generalization
The following treatment goals have been met under specific teaching conditions, but not mastered and
generalized (i.e., the client is not using these skills in different settings, with parents, etc.) as prescribed in
the treatment plan. Goals should be addressed weekly in order to ensure that learning is generalized.
These goals are also periodically probed during sessions to ensure maintenance of mastery with ES
Northern California staff.
Goal Generalization Criteria Date Introduced into
Generalization

Maintenance
The following treatment goals have been mastered and generalized as prescribed in the treatment plan.
These goals are periodically probed during sessions to ensure maintenance of mastery and generalization.
Goals that do not show maintenance of mastery and generalization may be placed back onto treatment
plans.
Goal Maintenance Criteria Date Introduced into
Maintenance
ZZZZTest Graduated Target: Not Available 11/16/2021
Status = Maintenance : Clean
House : Steps
ZZZZTest 9/9 : Naturalistic Not Available 11/08/2021
Teaching : Maintenance
ZZZZTest Maintenance : TA : Not Available 11/09/2021
child 1 12312321

Summary of Progress in this Reporting Period

Client’s progress
wqeqwe
Behavioral and adaptive strengths and concerns
qweqwe
Family participation and family adherence to family participation plan and program requirements
qwewqe

Page 21 of 25
 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

Barriers to Service and Dangerous Behaviors

BARRIERS TO SERVICE Environmental or family concerns are likely to have significantly impacted
service delivery in the last treatment period.
Yes
No

DANGEROUS BEHAVIORS Does client exhibit dangerous behaviors?

Inclusive of any dangerous behaviors observed during or outside of
treatment
Yes
No

Total Number of Goals Met/Not Met

Status of Goals Current Reporting Period
Total Goals 0
Goals Met 0
Goals Not Met 0
Goals Showing Little / No 0
Progress
Total Caregiver Training Goals 0
Caregiver Training Goals Met 0
Caregiver Training Goals Not Met 0
New Goals Added for Next 12
Reporting Period

Page 22 of 25
 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

Parent Participation in Program

Compliance with treatment recommendations and active parent/caregiver participation is essential to
optimal client progress in programs. Treatment aims at empowering parent(s)/caregiver(s) to independently
carry over strategies to their daily lives thus enabling independence and fulfillment for the client and their
family.
Empowers clients and parent(s)/caregiver(s) to actively participate with the team to promote
progress towards and achievement of desired outcomes. This includes encouraging
parent/caregiver participation in the client’s ABA treatment program and training
parents/caregivers in implementing treatment strategies.
Provides services that are consistent with the needs of each client through direct interaction with
the client and/or with their support system.
Provides services that are culturally and linguistically competent.
There are no specific rules (e.g. rules around cancelations of sessions) around parent/caregiver
participation.

Plan for Parent Participation

Attendance in meetings:
qwewqe
Participation during sessions:
qwewqe
Sustaining intervention outside of sessions:
qwewqe
Other:
wqeqweqe

Page 23 of 25
 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

Guidelines
Guidelines for Discharge from ABA Episode of Care
Discharge: Graduation Discharge: ABA not appropriate or no longer
appropriate
Cognitive potential has been reached Improvements are not maintained or
and no significant life interfering generalized OR
maladaptive behaviors are present OR There is a lack of meaningful progress
The client has achieved adequate (e.g. no change in adaptive domains)
stabilization and behaviors can be OR
managed in a less intensive Treatment is making the symptoms
treatment/environment OR persistently worse (e.g. maladaptive
The client can be treated with a less behavior occurs more during ABA
intensive level of care (e.g. community sessions; a trial of stopping ABA results
social program) OR in improved behavior) OR
Behavior change is meaningful and Client becomes too fatigued with
sustainable (see definition of meaningful school/Day Program and ABA OR
change) OR Family members / caregivers are unable
Behavior is within normal limits when to support ABA and no or minimal
compared to peers without ASD who progress has been made as a result
have a similar intellectual level (e.g. excess cancelations result in no
progress). NOTE: Discharge is based
on progress not parent participation.
Before discharge every effort should be
made to support family/parents so that
ABA can continue OR
Client is 12 or older and has the ability
to decline ABA (e.g. can express their
desire to stop ABA) OR
Behavior is more related to non-ASD
mental health symptoms such as an
anxiety disorder

Report Reviewed with Family and Client?

Date you met with client/family to provide update and obtain their input on treatment. Ensure client/family is
provided a copy of this report following its approval.
Yes

Page 24 of 25
 Client Name: ZZZTest myBrightlink PROD Test
Client Scheduling ZZZTESTING
MRN: number
Date of Report: 11/07/2021
Transfer Report

Reviewed date:
11/07/2021

Please contact your Clinical Manager, your Regional Director, or the BHPN Clinical Case Manager at 855-
843-2476 (855-the-BHPN) directly with any additional questions or comments related to this report.

Respectfully Submitted,

qwewqe qwewqe, wqeqwe qwewqe 11/07/2021

Signature Name and Title License/Cert. # Date

Page 25 of 25