The Homestead Name: XXXX

Innovative solutions for people with autism DOB: XXXXX

Medicaid #: XXXXXX
Quarterly Behavior Support Plan Review:
Client’s Name: XXXX
Date of Birth: XXXXXXX

Quarter 1
Due Date: 11/10/20017
Review Date:
Contacts Made and
Staff (10/27/2017)
Date:

Summary:
Include restrictions
currently in place

XXXXXX had a goal of engaging in 2 or less intervals daily with self-

injurious behavior (SIB). XXXXXX met his goal for 2 or less intervals of self-
injurious behavior (SIB) in August with an average rate of 1.1 per session.
The rate increased in September to 2.1, staying slightly above the goal.
XXXXXX had an additional goal of engaging in 1 or less intervals of
aggression toward others for 1 or less intervals for 80% of sessions.
XXXXXX met this goal for all three months of the summer.

See progress summary for period 7/1/2017 – 10/1/2017 for additional

information.
Continue BSP with updates. See progress summary for period 7/1/2017 –
Action:
10/1/2017 for recommendations.

Plan written by:

Wendy, Clinic Supervisor 10/27/2017

The Homestead Name: XXXX
Innovative solutions for people with autism DOB: XXXXX
Medicaid #: XXXXXX

Quarterly Behavior Support Plan Review:

Client’s Name: XXXXXX
Date of Birth:
Effective Date: 2/01/2018

Quarter 2
Due Date: 2/01/2018
Review Date: 1/31/2018
Contacts Made and Staff: 1/31/2018
Date: Parents: 2/13/2018

Data Collection:
Include graphs, raw
data, or summary

XXXXXX’s rates of SIB have increased slightly from last quarter; from an
average rate of 2.7 per session to an average rate of 3.3 per session.
Currently, XXXXXX is on a DRA token economy of having a calm body
which includes not engaging in SIBs. The rate in which he receives his
tokens is at 1 minute. This token economy will be run at an increased
frequency throughout the session. Currently, it is run on an average of 3
Summary:
times per session.
Include restrictions
currently in place
XXXXXX’s aggression and scream/cry has continued to decline to below
goal levels. Functional communication targets will be continued in order
for XXXXXX to replace these behaviors.

There are currently no restrictions.

Action: Continue BSP with updates.

The Homestead Name: XXXX
Innovative solutions for people with autism DOB: XXXXX
Medicaid #: XXXXXX

The Behavior Support Plan and Restrictions (if applicable) have been reviewed with me:

Name/relationship to person served Date

Plan written by:

Wendy Prince, Clinic Supervisor Date

Plan reviewed and supervised by:

Lisa Daniel-Way, Clinic Director Date

The Homestead Name: XXXX
Innovative solutions for people with autism DOB: XXXXX
Medicaid #: XXXXXX

Quarterly Behavior Support Plan Review:

Client’s Name:
Date of Birth:
Effective Date:

Quarter 3
Due Date:
Review Date:
Contacts Made and
Date:
Data Collection:
Include graphs, raw
data, or summary
Summary:
Include restrictions
currently in place
Action:

The Behavior Support Plan and Restrictions (if applicable) have been reviewed with me:

Name/relationship to person served Date

Plan written by:

Name, Clinic Supervisor Date

Plan reviewed and supervised by:

Name/Credentials Date
The Homestead Name: XXXX
Innovative solutions for people with autism DOB: XXXXX
Medicaid #: XXXXXX