DocuSign Envelope ID: 601659CB-A6A2-4BC6-9525-564A1BA568D0

Phone: (980)785-1113 Fax: (980) 785-1114

www.mosaictherapy.com

Client Name: Diego Espinoza Client Date of Birth: 05/21/2015 Gender: Male

Date(s) of
Assessing Clinician: Katheryne Paige Assessment: 03/27/2024 03/28/2024 03/29/2024 Assessment Location: Clinic
Byrum, BCBA, LBA
Date of Report: 04/01/2024

CPT Code: 97151 Client Diagnosis/ICD10: (F84.0) Autistic disorder Time of Assessment: 3:00pm
Client ID: 3165581 Insurance ID: 986066115

I. Reason for Referral

Diego Espinoza was referred to Mosaic Pediatric Therapy by Michelle Einson Psy.D.for Applied Behavior Analysis (ABA)
services to address signs and symptoms related to autism spectrum disorder as set forth by the DSM-V criteria. Per the
assessment report, skill deficits have been identified in the following domains: social communication, social interactions,
and the presence of restricted repetitive interests and patterns of behavior.

II. Background Information

Diego is an 8-year-old male. He lives with his mother, father, and sister. His family relocated from Chile to the United
States in September 2023. A medical evaluation and report was completed by a pediatric neurologist, Dr. Lorena
Pizarro Rios, on July 27, 2023 in Chile prior to his move to the U.S. The diagnoses findings included in the report for the
evaluation included: Level 3 Autism Spectrum Disorder, Severe Mixed Language Disorder 2nd to ASD, and Combined
Attention Deficit Disorder. Diego was evaluated by Michelle Einson Psy.D. at STEPP in Charlotte, North Carolina on
November 15, 2023 at the request of his insurance provider upon his relocation to the United States in order to
determine his eligibility for ABA treatment. This evaluation confirmed Diego's diagnosis of Autism, Moderate to
Severe. Diego currently takes 20 mg of Methylphenidate once per day to treat symptoms related to ADHD. He also
takes 0.5 mg of Risperidone once per day. He has no known allergies.

Diego is in the 3rd grade at Sardis Elementary School. He receives special education services and has an Individualized
Education Plan in place. Diego receives speech therapy and occupational therapy through his public school. Based on
information provided by his father, Diego received approximately 6 hours per week of ABA therapy services for
approximately 3 months (from September to December).

III. Summary of Parent Interview

A parent interview was conducted to collect additional information from Diego's father and to identify the family's most
significant concerns at this time. Diego's parent's top goals for ABA treatment are to develop and increase his functional
communication repertoire, reduce the frequency of his aggressive grabbing behaviors, and to increase his flexibility with
eating different foods.
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IV. Summary of Records Review

The BCBA reviewed Diego's medical evaluation report from July 2023 (Chili) and his most recent evaluation and
diagnostic report from November 2023 (U.S.). The CARS-2 was used by Michelle Einson, Psy.D., as a tool to help confirm
Diego's diagnosis of autism. It was noted that Diego's scores on the CARS-2 were reported in a descriptive rather than
a quantitative manner as this tool may not have been standardized for use with individuals from linguistically or
culturally diverse backgrounds. The CARS-2 assessment report stated that Diego does not attempt to interact with
children other than his older sister. He does not respond to others' attempts to engage him in play. His eye contact did
not appear to be socially purposeful. His imitation skills for words and simple actions were reported as normal. He
shows a range of facial expressions and nonverbal emotional responses including frustration, enjoyment, and sadness,
although he tends to be overly passive. Diego sometimes flaps his hands when he becomes frustrated or excited,. He
also tends to squeeze his parents' faces when he becomes excited or upset. He was reported to show signs of
hypersensitivity to some noises and exhibits stereotyped interests in items by smelling toys. He often lines up objects
and interacts with the same items in a repetitive manner with no purposeful or imaginative play.

Diego is toilet trained. He completes daily living skills with adult supervision. Diego exhibits delayed echolalia. He
communicates by leading others to what he wants, getting the item himself, or exhibiting negative behaviors when he
becomes frustrated. He produces a small number of single word and word approximations to make requests for a
limited number of items/activities. These spoken requests are spoken in Spanish which is his family's primary language.

He engages in sensory seeking behaviors in the form of deep pressure and prolonged atypical visual gaze. These
behaviors have been reported to be disruptive at times. Diego enjoys gross motor vestibular activities such as running,
swinging, jumping, and swimming. He also enjoys watching videos. Information in his medical records indicate a
hypersensitivity to some noises and an aversion to certain textures and some forms of physical touch that are not
initiated by him. Diego reportedly follows familiar instructions in the context of daily routines. He has difficulties waiting
for his requests to be honored and becomes frustrated in these types of situations. Based on the background
information included in his medical report, previous efforts at instruction for communication have included a combination
of several different alternative methods of speaking including selection-based systems (pictures, words).

V. Assessment Results

Indirect Assessment(s):

Diego Espinoza was evaluated using the Vineland-3 Comprehensive Parent/Caregiver Form on 03/28/2024. Diego A.
Espinoza, Diego's father, completed the form. Diego's overall level of adaptive functioning is described by his score on
the Adaptive Behavior Composite (ABC). His ABC score is 50, which is well below the normative mean of 100 (the
normative standard deviation is 15). The percentile rank for this overall score is <1.
The ABC score is based on scores for three specific adaptive behavior domains: Communication, Daily Living Skills, and
Socialization. The domain scores are also expressed as standard scores with a mean of 100 and standard deviation of
15.
The Communication domain measures how well Diego listens and understands, expresses himself through speech, and
reads and writes. His Communication standard score is 42. This corresponds to a percentile rank of <1. This domain is a
relative weakness for Diego.
The Daily Living Skills domain assesses Diego's performance of the practical, everyday tasks of living that are
appropriate for his age. His standard score for Daily Living Skills is 54, which corresponds to a percentile rank of <1.
This domain is a relative strength for Diego.
Diego's score for the Socialization domain reflects his functioning in social situations. His Socialization standard score is
38. The percentile rank is <1. This domain is a relative weakness for Diego.

Direct Assessment(s):
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VB-MAPP Barriers Assessment

The VB-MAPP’s Barriers Assessment provides an assessment of 24 common learning and language acquisition barriers
faced by children with autism or other developmental disabilities. The barriers include behavior problems, instructional
control, defective mands, defective tacts, defective echoic, defective imitation, defective visual perceptual/MTS, defective
listener skills, defective intraverbal, defective social skills, prompt dependency, scrolling, defective scanning, defective
conditional discriminations, failure to generalize, weak motivators, response requirement weakens the motivators,
reinforcer dependency, self-stimulation, defective articulation, obsessive compulsive behavior, hyperactive behavior,
failure to make eye contact, and sensory defensiveness. A higher score indicates more significant barriers.

Diego scored a 74 out of 96 on this assessment indicating significant barriers to learning and language development
are present.

Essential For Living Skills (EFLS)

An initial assessment of Diego was conducted using Essential for Living (EFL), a functional skills assessment and
curriculum designed for children and adults with moderate-to-severe disabilities. This instrument includes “The Essential
Eight” skills, also known as “must-have skills”, which are necessary to ensure that these children and adults lead safe,
happy, and fulfilling lives and that they are integrated into community living to the greatest extent possible.

Spoken Words: Diego exhibits a few spontaneous spoken words and spoken-word repetitions in Spanish, which are
understandable. He engages in vocal stereotypy and delayed echolalia. These vocalizations were not easily
understood by the BCBA during the direct assessment on 3/29/2024. He was able to repeat single word
approximations in English when prompted by the assessor (ball, come, up, all done).

The Essential Eight Skills: The following skills were assessed by noting ‘possible skill deficits’ using the EFL Quick
Assessment or directly observing Diego and confirming those skill deficits by testing Diego in situations in which each of
these skills would be expected to occur.

1. Making requests (EFL, Domain 1): Diego currently makes requests by leading others to what he wants or getting
it himself. He produces single vocal words in the Spanish language for a small number of requests. According to
his father, Diego will ask for water, says “pee pee” when he needs to go to the bathroom, and makes requests
for car (“auto”) or home (“casa”) when he wants to leave and/or go home. During the direct assessment,
motivating preferred items and activities were identified. Diego actively approached adult(s) to gain access to
tangible reinforcement. When the assessor probed the use of a picture selection based system as an alternative
method of speaking for Diego to make requests, he displayed resistance to physical prompts. He engaged in
whining along with mild aggression in the form of grabbing the assessor’s face when modeling and gesture
prompts were used to show Diego how to use this method of speaking. It was unclear if this method was
aversive due to a past history of PECS training or if his frustration was related to an increase in response effort.
Diego did tolerate verbal prompts from the assessor by echoing single word approximations that were spoken in
English for ball, come, up, all done. An echoic to mand transfer with time delay was not successful and echoic
prompts were difficult to fade, however, Diego did eventually produce an independent response one time for 2
different requests by the end of the assessment: ball (“bah”), all done (“ah duh”). He produced one
spontaneous vocal request, “casa”, to communicate his assent withdrawal and that he was ready to end the
assessment. Diego did not attempt to use functional communication to request for the opportunity to engage in
activities related to his stereotyped behaviors (lining up items or to seek sensory input in the form of squeezes
from his father). Diego sometimes said "okay okay" and pushed away items as a request for the removal or
termination of an aversive stimulus or demand. It is important to note that immediate echolalia was observed for
listener instructions that were delivered after echoic trials were probed as a strategy to prompt vocal
requests. Diego's motivation was limited to gross motor play, sensory input, and nonfunctional use of items (i.e.,
going down a slide structure, prolonged visual gaze, gathering similar items, and lining up items). He exhibited
restricted and repetitive interests and patterns of behavior. During the assessment, Diego was able to perform a
chain of motor responses for a play activity after an adult demonstration, however, he then performed this same
sequence of play behaviors in a repetitive manner throughout the assessment: climb up ladder, roll ball down
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slide, go down slide. (Score: 3)

Programming will focus on increasing Diego's independence and consistency in using functional communication to
make requests for 10 or more preferred items or activities without prompts that can be made immediately and
frequently available and to request the opportunity to engage in highly preferred stereotypic activity. He will also
be taught to appropriately request for the removal or termination of an aversive stimulus without prompts and
without engaging in maladaptive behaviors. Programming will also focus on expanding Diego's interests and play
behaviors.

2. Waiting after making requests (EFL, Domain 1): Diego made one spontaneous request to the BCBA toward the
end of the direct assessment after multiple tasks were presented to him. The assessor probed Diego's ability to
tolerate a delay in his request being honored. He was observed to repeat his request and/or engage in grabbing
the adult when his request or other indicating responses were not immediately honored (less than 1 minute). This
skill was not assessed for any other items/activities due to Diego not making other spontaneous requests.
According to his father, Diego does not tolerate delays when he wants something.(Score: 2)

Programming will focus on development of Diego's spontaneous mand repertoire and then, once spontaneous
requests are occurring with consistency, waiting for his requests to be honored will be taught for gradually
increasing periods of time.

3. Accepting removals, making transitions, sharing, and taking turns (EFL, Domain 1): When Diego is required to
accept the removal of preferred items and activities and to make transitions, he sometimes shows resistance
and/or engages in aggressive behaviors in the form of grabbing others. During the direct assessment, when
items related to Diego's redistricted and repetitive behaviors were manipulated or removed by the BCBA or by a
peer, Diego reacted negatively by either engaging in whining/complaining vocalizations (saying "eh eh eh"),
taking the item back, or grabbing the other person's face or arm. Diego transitioned with the BCBA to preferred
items/activities. Diego did not cooperate with transitioning from gross motor play activities to any of the skills-
based tasks when those materials were presented by the assessor. (Score: 1)

Programming will focus on accepting removals, others manipulating his items, and making transitions from
preferred to less preferred or non-preferred tasks (R10 and R13).

4. Completing 10 consecutive, brief, previously acquired tasks (EFL, Domain 1): Diego followed adult instructions to
engage in enjoyable gross motor activities in the gym with modeling and gesture prompts. When the assessor
presented the materials (pictures) and verbal instructions to assess Diego's accuracy and cooperation with
completing several skill-based tasks (emotions, body parts), he showed assent withdrawal behaviors by either
pushing away the items or returning the items to their container. These behaviors were accompanied or
immediately followed by the spontaneous vocalization, "okay okay", or a vocal mand for home, "casa". (Score: 1)

Programming will focus on Diego following adult instructions to engage in required tasks less preferred activities
when directed to do so when an unrelated reinforcer is delivered on a specified reinforcement schedule. These
tasks will require varying degrees of response effort and will be for varying durations.

5. Accepting ‘No’ (EFL, Domain 1): According to his father, when Diego is told he cannot have something or do
something that he wants, he generally accepts this denial. During the direct assessment, Diego accepted 'no' for
neutral items but required additional prompting when he was told 'no' for highly preferred items related to his
sensory seeking or stereotyped behaviors. He showed aggression towards a peer by grabbing her face after she
denied his attempts to regain access to an item (scooter) that was related to his restricted repetitive behaviors
(lining up similar items). He was able to be redirected by the BCBA to another nearby item/activity that was
available without additional escalation. (Score: 1)

Programming will focus on Diego consistently accepting no for highly preferred items/activities including his
requests related to his sensory seeking or repetitive behaviors without exhibiting aggression.

6. Following directions related to health and safety (EFL, Domain 2): It is reported that when Diego is given
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instructions in the context of daily routines he is usually successful at following those instructions as long as he
understands. During the direct assessment, Diego followed single-step instructions that were spoken by the
assessor in English to perform contextually-related motor responses when the listener instruction included a
gesture prompt (give to me”, "roll ","slide down”, “high-five”, “close door”. He did not respond to any of those
same single-step instructions that were delivered without a gesture prompt. Diego did respond appropriately to
the listener safety instruction, “come here” with a gesture. He did not respond to directions related to safety like
“stop” for him to stop moving or engaging in a motor activity when directed to do so. Diego did appropriately turn
toward the speaker when his name was called from varying positions and distances across 100% of
opportunities. (Score: 2)

Programming will focus on Diego responding to listener instructions to perform motor responses in the context of
daily routines and specific directions related to health and safety without the need for additional prompting.

7. Completing daily living skills related to health and safety (EFL, Domain 4): These skills were not directly tested
during the assessment. According to records and information shared by his parent, Diego completes most activities
of daily living skills related to health and safety with adult supervision. (Score: 4)

8. Tolerating situations related to health and safety (EFL, Domain 6): These skills were not directly tested during
the assessment. According to records and information shared by his parent, Diego tolerates most routine
activities related to health and safety without problem behavior. (Score: 4)

VI. Treatment Plan

Goal Area: Goals to remediate impairments related to restricted and repetitive patterns of
behavior, interests, or activities

Goal: Diego will show variation and spontaneity in functional play actions by performing multiple play responses with a single
toy/activity made available to him, for 5 different sets of toys or play activities.
Mastery Criteria: 3 different play actions without interfering stereotyped behaviors and without adult prompts on the first
opportunity of the session for 3 consecutive data points, across 5 different types of toy items/activities.
Current Level of Performance: Diego performed a chain of 3
motor play responses only after adult prompts were given. He
then performed this same chain of play actions in a repetitive
Baseline: 0
manner throughout the direct assessment. Other attempts made
by the BCBA to entice Diego to engage in functional play with
different items were not successful.
Goal Status: New goal Projected Date of Mastery: October 2024

Goal: Diego will tolerate delays in reinforcement for gradually increasing periods of time, up to 5 minutes.
Mastery Criteria: waits the required duration (with access to other available items) without repeating his request, without leaving
the area, and without engaging in disruptive behaviors across 5 trials per day for 5 consecutive days with data collected
Current Level of Performance: Diego waited less than 60
seconds after making a request. He then repeated his request
Baseline: <60 seconds and/or grabbed his communication partner. According to his
father, Diego has difficulties with waiting for something that he
wants.
Goal Status: New goal Projected Date of Mastery: October 2024

Goal: Diego will follow instructions to engage in required tasks or less preferred activities when directed to do so by his adult,
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without protest or problem behaviors, when an unrelated reinforcer is delivered on a specified reinforcement schedule.
Mastery Criteria:100% accuracy once per session for 3 consecutive therapy days with data collected across 5 different tasks of
varying durations and requiring varying degrees of response effort.
Current Level of Performance: Diego follows adult instructions
to engage in preferred activities when directed to do so in the
natural environment. Diego did not complete any of the less
Baseline: 0 preferred tasks presented by the BCBA during the direct
assessment. He communicated his refusal of assent by pushing
or putting the materials away and saying "Okay okay" and/or
spontaneously manding "Casa" for to go home.
Goal Status: New goal Projected Date of Mastery: October 2024

Goal: Diego will accept 'no' when his requests to access highly preferred items/activities are denied (including those related to his
sensory seeking or stereotypic behaviors or requests for the removal of termination of an aversive stimulus).
Mastery Criteria: 100% accuracy on 3 consecutive occasions without repeating the same request, without aggressive behaviors,
and continues making other required responses in 2 different situations, and with either of 2 different adults.
Current Level of Performance: According to his father, when
Diego is told he cannot have something or do something that he
wants, he generally accepts this denial. During the direct
assessment, Diego accepted 'no' for neutral items but required
additional prompting when he was told 'no' for highly preferred
Baseline: 0
items related to his sensory seeking or stereotyped behaviors.
He showed aggression towards a peer by grabbing her face
after she denied his attempts to regain access to an item
(scooter) that was related to his restricted repetitive behaviors
(lining up similar items).
Goal Status: New goal Projected Date of Mastery: October 2024

Goal: Diego will respond appropriately to listener instructions to perform motor actions in the context of daily routines and
specific directions related to health and safety without the need for additional prompting.
Mastery Criteria: 100% accuracy within 3 seconds, without prompts, on the first trial of the day across 3 consecutive therapy
days with data collected for each of 8 different target instructions and a generalization probe for 2 novel untrained listener
instructions

Current Level of Performance: It has been reported that when

Diego is given instructions in the context of daily routines he is
usually successful at following those instructions as long as he
understands. During the direct assessment in the clinic setting,
Diego followed single-step instructions that were spoken by the
assessor in English to perform contextually-related motor
actions when the verbal direction included a gesture prompt for
5 different instructions: “give to me”, "roll ","slide down”, “high-
five”, “close door”. He did not respond to the same verbal
Baseline: 0 directions when they were delivered without a gesture prompt
from the BCBA.

He responded appropriately to the listener safety instruction,

“come here” with a gesture. He did not respond to other verbal
directions related to safety (e.g., “stop”, “wait”) for him to stop
moving or engaging in a motor activity within 3 seconds. Diego
did appropriately turn toward the speaker when his name was
called from varying positions and distances across 100% of
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opportunities.

Goal Status: New goal Projected Date of Mastery: October 2024

Goal Area: Goals to remediate impairments related to Social Communication and Social
Interaction

Goal: When motivation is present, Diego will use functional communication to make requests for 10 different preferred
consumable items, non-consumable items, and/or activities that can be made immediately available.
Mastery Criteria: independent on the first opportunity of the day when motivation is present, without prompts, without scrolling,
and without maladaptive behaviors, complaints, and without leaving the area for 3 consecutive days with data collected, in the
presence of either of 2 different people
Current Level of Performance: Diego spontaneously manded
"Casa" as a request to leave during the direct assessment. This
type of request would not be frequently and immediately
Baseline: 0 available during his ABA therapy sessions. He often leads others
by the hand to make requests. According to his father, Diego
will ask for water, to "pee pee", and will say "auto" or "casa" as
a mand to go.
Goal Status: New goal Projected Date of Mastery: October 2024

Goal: Diego will use functional communication to request the opportunity to engage in stereotypic movements with items, engage
in highly preferred stereotypic activities, or to access preferred sensory input.
Mastery Criteria: independent on the first opportunity of the day when motivation is present, without prompts, without scrolling,
and without maladaptive behaviors, complaints, and without leaving the area for 3 consecutive days with data collected, in the
presence of either of 2 different people
Current Level of Performance: At this time, Diego does not
request permission for the opportunity to access desired
sensory input (deep pressure, squeezes) or engage in restricted
repetitive behaviors (collecting items, lining up items). He will
often squeeze his parents' faces when he becomes excited. He
Baseline: 0 also seeks this type of sensory input when he becomes upset.
During the direct assessment, Diego retrieved and lined up a
set of at least 10 different large items which became disruptive
to the environment and his participation. He did not use
prompted or unprompted functional communication to request
the opportunity to engage in this activity.
Goal Status: New goal Projected Date of Mastery: October 2024

Goal: Diego will share and take turns with preferred items/activities during required situations of this type when motivating
events are strong.
Mastery Criteria: 80% of 5 daily contrived situations are absent of excessive complaining, aggression towards the target adult or
peer, resistance to prompts, or attempts to leave the area for 3 consecutive days with data collected across 2 or situations and
involving either of 2 different peers/adults.
Current Level of Performance: When Diego is required to accept
the removal of preferred items/activities or is required to share
or take turns, he sometimes shows resistance and/or engages
in aggressive behaviors in the form of grabbing others. During
the direct assessment, when items related to Diego's
Baseline: 0%
redistricted and repetitive behaviors were removed by the
BCBA or by a peer, Diego reacted negatively by either
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Goal Status: New goal
engaging in whining/complaining vocalizations (saying "eh eh
eh"), taking the item back, or grabbing the other person's face
or arm.
Projected Date of Mastery: October 2024

Goal: Diego will use functional communication to independently request for the removal or termination of an aversive stimulus
(e.g., "no", "stop") in 2 different situations.
Mastery Criteria: independent on the first opportunity of the therapy session when motivating events occur, without aggressive
behaviors or excessive complaining, without prompts, without scrolling, and within 3 seconds for 3 consecutive days with data
collected and with either of 2 different adult providers.
Current Level of Performance: During the direct assessment,
Diego exhibited inappropriate responses, complaining, or
aggressive behaviors to mand for the removal of termination of
Baseline: 0 unwanted stimuli across 2 different types of situations (others
manipulating the objects related to his stereotypic use of items;
the presentation of materials that signaled a demand to
complete a less preferred skill-based task).
Goal Status: New goal Projected Date of Mastery: October 2024

VII. Goals to target behavior reduction

Summary of any problematic behaviors targeted for reduction:

During the direct assessment, Diego exhibited aggression in the form of forceful grabbing another person (face, arm).
There were 6 instances of this behavior (1 involving another child, 5 involving the assessing BCBA).

The antecedent(s) that preceded these behaviors involved someone removing or interfering with his access to an
item/activity when motivation was strong (related to a restricted repetitive behavior), and/or a demand was placed
that required an increase in response effort (a prompted functional communication response), or there was a delay in
his request being honored (when Diego said "casa" to request for the termination of the direct assessment).

He engaged in a high rate of vocal stereotypy during unstructured activities, however this behavior will require further
assessment and monitoring to determine if there is a need for intervention.

Goal: Diego will reduce the frequency of his aggression towards others (forceful grabbing body parts of others).
Mastery Criteria: 0 instances per day for 10 consecutive days with data collected.
Current Level of Performance: Diego exhibited aggression in
the form of forcefully grabbing another person's face or arm
Baseline: 6 instances
(assessing BCBA, peer) on six different occasions during the
assessment when he became frustrated.
Goal Status: New goal Projected Date of Mastery: October 2024

VIII. Parent Participation and Goals

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Parent Participation Statement:

Diego's parents will be expected to participate in family training with the BCBA on a monthly basis during the
authorization period to support generalization and success of treatment. Family members/caregivers may be asked to
record and submit data for the supervising BCBA to review and make additional recommendations for treatment.
Behavior skills training (BST) will be utilized for family training and will require active participation between the BCBA
and family member(s) in the form of instructions, modeling, rehearsal, and feedback. Data will be collected on
participation and progress towards goals.

Parent/Caregiver Goals:

Goal: Diego's family will implement functional communication training procedures to support the development and generalization
of his spoken mand repertoire.
Mastery Criteria: avg 80% accuracy according to a BCBA developed fidelity checklist across 3 opportunities of role-play,
rehearsal, or direct observation
Baseline: Treatment not initiated Current Level of Performance: Treatment not initiated

Goal Status: New goal Projected Date of Mastery: October 2024

Goal: Diego's family will implement antecedent manipulations and reinforcement procedures identified as effective for increasing
his food flexibility.
Mastery Criteria: Diego consumes a non-preferred food without signs of displeasure or problem behaviors based on 3 instances
of self-reports and/or written data from parents
Baseline: Treatment not initiated Current Level of Performance: Treatment not initiated

Goal Status: New goal Projected Date of Mastery: October 2024

ration with Related Services

The therapy team will work as needed with any available community resources to ensure continuity between programs.
This will include providing copies of Assessment Reports and data, given written consent, to all other providers that
provide services to Diego.

Diego's father agreed to provide a copy of his individual education plan and to support any future collaboration
between service providers, including Diego's IEP team.

X. Generalization

Generalization is targeted throughout the authorization by using instructional design techniques that promote
generalization such as multiple exemplar training, general case analysis, teaching non-examples, programming common
stimuli and teaching loosely.

XI. Service Delivery

It is recommended that Diego participate in a comprehensive ABA treatment model to remediate his symptoms of
autism. Treatment will take place in the clinic setting with generalization to the home and community when
appropriate.
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Service Recommendations

Per Authorization
97151 Behavior Identification Assessment 8 Hours 32 Units
Period
Per Authorization
97152 Adaptive Behavior Assessment Procedures 0 Hours 0 Units
Period
97153 Adaptive Behavior Treatment 30 Hours 120 Units Per Week
Adaptive Behavior Treatment with Protocol
97155 23.75 Hours 95 Units Per Month
Modification
Adaptive Behavior Treatment with Protocol Per Authorization
97155 10.50 Hours 42 Units
Modification - Telehealth Period
97156 Family Adaptive Behavior Treatment Guidance 1 Hours 4 Units Per Month
Family Adaptive Behavior Treatment Guidance -
97156 1 hours 4 units Per Month
Telehealth

XII. Discharge Planning

Treatment duration is effectively managed by evaluating the client's response to treatment. Some individuals will
continue to demonstrate medical necessity and require continued treatment across multiple authorization periods.
Discharge and transition planning should generally involve a gradual step down in allocation of services.

At each assessment, discharge from services or transition to a lower number of hours is considered. Discharge from
behavioral, evidence-based treatment is recommended when Diego meets the following criteria:
1. Discharge will be initiated when no new socially significant objectives are identified in future assessments that are
relevant to the reduction of impairment related to an autism diagnosis.
2. Discharge will be initiated if it is determined that Diego's skills will come under the natural contingencies of
reinforcement if taught using incidental teaching procedures implemented by the parent rather than focused, contrived,
and individual treatment.
3. Discharge will be initiated when Diego demonstrates an established and generalized functional communication
repertoire so that he is able to make requests for a majority of his wants/needs, in more than one setting, and with
familiar and unfamiliar communication partners.

Discharge may also be initiated if:

1. Diego is no longer able to actively participate in therapy sessions.
2. Diego's needs can be fully addressed via other appropriate services not provided by Mosaic Pediatric Therapy (school
-based services, psychology, psychiatry, other special therapies).
3. Diego fails to make measurable progress in the target areas as measured by failure to master 80% of the goals on
the treatment plan across successive 6-month authorization periods assuming he participates in the recommended
treatment dosage.
4. The severity of Diego's behavioral issues is so significant that it exceeds the level of care that can be offered within
the clinical model of Mosaic Pediatric Therapy.
5. The parent(s) choose(s) to terminate services.

Katheryne Paige Byrum, BCBA, LBA 4/8/2024

Program Manager, BCBA, LBA

Parent/Caregiver Signature

Diego Espinoza