Maladaptive Behavior Summary
Client Information
Client Name
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DOB
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Date
Medicaid Number
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Client Age
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Client/Caregiver Demographics
Parent’s Name
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Phone
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Address
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Medical Doctor’s Information
Doctor’s Name
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Phone
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The client engages in the following maladaptive behaviors
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Aggression
Self-injurious behavior
Tantrums
Inappropriate feeding behavior
Elopement
Yelling/Screaming
Property destruction
Perseverative behaviors
Other
Additional details related to ABA Therapy:
Explain how maladaptive behaviors have impacted the client’s daily functioning and/or quality of life:
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