Wall Therapeutic Solutions ABA and Therapeutic Consultation in VA

1. Please Indicate the Therapeutic Consultation Service Interested In:

Behavior

Speech

Psychological

Recreation Therapy

Are you interested in participating in sessions remotely through telehealth?

Yes

2. Individual Being Referred for Services

Primary Language of Individual

Primary Language of Legal Guardian

3. Individual Making Referral

Individual Making Referral

Relation to Individual:

Parent

Grandparent

Legal Guardian

Family Member

Non Family Member

Support Coordinator

Program Manager

Educator

REACH

Other Provider

4. Residential Service Provider (If Applicable)

Service Provider (Agency/Name)

Parent Provider?

Yes

5. Service Funding Source and Services Requested: Waiver

Requested Services

Therapeutic Behavior Consultation (Medicaid Waiver - FIS and CL only)

Behavior Consultation (Alternate funding source)

6. Diagnoses and Other Services

Diagnosis (please select all that apply)

F84.0: Autism

F70: Mild Intellectual Disability

F71: Moderate Intellectual Disability

F72: Severe Intellectual Disability

F73: Profound Intellectual Disability

F79: Unspecified Intellectual Disability

Other Treatments and Services Currently Being Utilized (Check all that apply)

Personal Assistance

Respite

Speech/Language Therapy

Occupational Therapy

Physical Therapy

Outpatient Counseling

Group Counseling

Companion Services

REACH

Group Day Services

Group Supported Employment

Individual and Family/Caregiver Training

Inhome Support Services

Workplace Assistance

Residential Services

7. ISP Aligned Shared Outcomes that Therapeutic Consultation services can address.

8. Describe the Interfering Behaviors (if applicable)

9. Please Indicate and Describe Communication Concerns

Communication Concern

Non-verbal or limited functional communication and pragmatic language

nintelligible or echolalic speech

Impairment in receptive

Where is your primary care doctor located ?

Phone Number of primary care doctor:

10. Please Describe Psychological Symptoms and/or Concerns

11. Please List domains/areas you feel recreation therapy may benefit this individual:

Yes

Please list current recreational activities the individual participates in or has interest in participating in in the future:

13. Other Information:

14. Preferred Items, Activities, and Environments:

Aversive Items, Activities, and Environments:

15. Current Residential, Educational, Mental Health, Skill Building, Community Engagement, Leisure, and Job Related Services

16. Current Medications - may also attach as document to the end of this referral form.

17. Current Schedule

Referring Source Signature

Clinician- No other signatures required but please ensure that all stakeholders are aware of the referral, requirements, and have had all questions answered prior to submitting authorization requests.

Date of Initial Staff Contact with Referring Source

Please attach any documentation here:

Choose File

Date of Initial Staff Contact with Referring Source

Reason for Referral:

Results of Initial Contact:

Intake for Services

Placed on Waitlist

Referred Out to Other Provider(s)

If Referred to Other Provider(s), Please List Those Provider(s) Here:

Referral

2. Individual Being Referred for Services

3. Individual Making Referral

Behavioral

Speech/Language

Psychological

Recreation Therapy

Other

15. Current Residential, Educational, Mental Health, Skill Building, Community Engagement, Leisure, and Job Related Services