Behaviour Therapist Template

Behavioural Analyst Note

A professional Behaviour Therapist template for healthcare professionals.

About this template

Need a clear and concise way to document your behavioural therapy sessions? This Behavioural Analyst Note template is perfect for behaviour therapists and other professionals working with individuals with autism and other developmental conditions. It helps you record essential information like patient history, observations, interventions, and progress. This template ensures comprehensive documentation, aiding in effective treatment planning and progress tracking. With Heidi, this template can be quickly populated from your session transcript, saving you time and improving accuracy.

Preview template

Subjective: - The patient presents with increased instances of self-injurious behaviour (SIB), specifically head-banging, occurring multiple times daily. Onset was approximately two weeks ago, coinciding with a change in classroom placement. Triggers appear to be transitions and periods of unstructured time. The patient has been observed to stop the behaviour when redirected by staff. - The patient has a history of autism spectrum disorder (ASD), diagnosed at age 3. Previous interventions have included Applied Behaviour Analysis (ABA) therapy and medication management for anxiety. - No neurological symptoms reported. - No past medical or surgical history of note. - The patient attends school, has a supportive family, and enjoys playing video games. Sleep quality is reported as adequate. - The patient is currently taking Risperidone 1mg daily for behavioural control. - No family history of neurological conditions. - No current substance use. Objective: - Stakeholder reports from the classroom teacher indicate an increase in SIB and difficulty with transitions. The patient's behaviour is also impacting their ability to participate in classroom activities. There is no risk to others. - The patient demonstrates appropriate spatial awareness and sensory responses. No cognitive deficits were observed during the assessment. - The patient's most recent psychometric assessment (Vineland Adaptive Behavior Scales) showed a decline in adaptive behaviour scores. - No restrictive practices are currently being used. Assessment: - The patient's behaviour is consistent with a functional assessment indicating the SIB is maintained by escape from aversive tasks and attention from staff. - Areas requiring action include reducing SIB, improving transition skills, and providing staff training on proactive strategies. Plan: - Implement a comprehensive ABA plan including differential reinforcement of other behaviours (DRO), functional communication training (FCT), and antecedent-based interventions. Collaborate with the classroom teacher to implement strategies consistently. Consider a medication review. - Therapy sessions will be conducted three times per week for 60 minutes each. - Short-term goals: Reduce the frequency of SIB by 50% within four weeks. Long-term goals: Improve transition skills and increase participation in classroom activities. - Provide the patient with visual supports and social stories to aid with transitions. Educate the patient on coping strategies for managing anxiety. - Referrals to the speech therapist and occupational therapist to support communication and sensory needs. Interventions: - During the session, the therapist implemented DRO and FCT strategies. The patient was taught to request breaks using a visual prompt. The therapist also provided positive reinforcement for appropriate behaviours. - The patient responded well to the interventions, with a noticeable decrease in SIB during the session. No adverse reactions were observed. Evaluation: - The patient has shown some progress towards the treatment goals, with a slight reduction in the frequency of SIB. The patient is beginning to use the communication strategies taught. - The treatment plan will be modified to include additional strategies for managing anxiety and to address any emerging challenges. Additional Notes: - The patient was educated on the importance of emotional regulation and the use of coping strategies. The patient was also provided with information on healthy lifestyle habits. - Follow-up visits will be scheduled weekly for the next month, with ongoing monitoring of progress and adjustments to the treatment plan as needed. The patient's parents will be involved in the treatment process. - The patient expressed a preference for more structured activities and a desire to improve their social skills. Date: 1 November 2024

Subjective: - [Description of the current symptoms, including onset, duration, and characteristics of behaviour (e.g., triggers, precursors, actions taken to remedy) (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Patient's history of the present illness or condition leading to the consultation (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Review of systems pertinent to care, including any neurological symptoms, previous injuries, conditions affecting the individual] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Past medical and surgical history, especially related to brain and general health (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Lifestyle factors affecting health, such as exercise habits, sleep quality, family dynamic, friendships, school, stress levels, etc (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Current medications, supplements, etc. (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Family history of neurological conditions (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Current substance use, self medication, such as alcohol or elicit drugs etc. (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Objective: - [Stakeholder reports, Allied health findings, including environmental, social, health, medication or pain analysis, range of behaviours displayed, any risk to self or others (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Assessment of neurological function, if indicated, including spatial awareness, sensory testing, risk to self, risk to others and cognition, etc (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Results of any diagnostic tests performed or reviewed, including imaging studies, psychometric measures etc (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Restrictive Practices currently being used, including chemical, seclusion, mechanical, environmental, physical etc (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Assessment: - [Behavioural diagnosis or functional assessment based on the subjective and objective findings (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Identification of areas requiring action - risk to self and others, poor staff fit, stakeholders requiring education etc. (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Plan: - [Action plan, including specific techniques to be used, allied health reports or adjunctive therapies required (e.g., therapeutic exercises, occupational therapy, assistive technology, General Practitioner Complex Care Plan Development, Medication Review) (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Frequency and duration of the treatment plan (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Goals of treatment, both short-term (e.g., pain relief, staff training) and long-term (e.g., improved staff matching, functional improvements) (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Self-care recommendations or allied health recommendations mentioned to the patient (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Mention any referrals (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Interventions: - [Details of behavioural therapy and other allied health interventions performed during the visit (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Patient's response to treatment and any immediate improvements or adverse reactions observed (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Evaluation: - [Evaluation of patient progress towards treatment goals (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Modifications to the treatment plan based on patient progress and response (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Additional Notes: - [Patient education provided on emotional regulation, lifestyle modifications, and preventive measures (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Plans for follow-up visits and continued care (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Any concerns or preferences expressed by the patient (mention if available)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information, if deemed relevant create "End Notes" section and bullet point or omit completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)

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