SECTION A: DIRECT THERAPY SESSION
Session Information
- Date, start/end time, total duration
- Location
- Service type (e.g., 1:1 direct ABA therapy, group session)
- Therapist/technician name and credentials
- Client name and age
- Whether caregiver was present
Client Presentation
- Affect, mood, engagement level
- Notable physical or emotional state
- Changes from previous sessions
- Relevant contextual factors (e.g., medication changes, sleep, recent life events)
Programs and Targets Addressed
- Skill acquisition programs targeted, with specific target names as per treatment plan
- Behaviour reduction plans addressed
Session Activities and Teaching Procedures
- ABA teaching methods used (e.g., DTT, NET, incidental teaching, chaining, shaping)
- Session structure (e.g., table work, naturalistic play-based, community-based)
- Specific activities and their connection to target programs
- Any modifications to planned activities and rationale
Data Collection Summary
For each program/target:
- Program/target name
- Data type (e.g., trial-by-trial, frequency, duration, percentage)
- Performance summary (e.g., accuracy, frequency count)
- Prompt level used
- Comparison to previous session (improving, maintaining, declining, variable)
- For challenging behaviour: ABC data (antecedent, behaviour, consequence)
Prompting and Prompt Fading
- Prompting strategies used (verbal, gestural, model, physical, visual)
- Progress with prompt fading
- Client’s response to different prompt levels
Reinforcement Strategies
- Reinforcement schedule used
- Effective reinforcers identified
- Changes to reinforcement and their effectiveness
- Preference assessments conducted
Challenging Behaviours
- Frequency, duration, and/or intensity
- Antecedents, observable behaviour description, consequences provided
- Patterns observed
- Effectiveness of behaviour intervention strategies
Barriers and Challenges
- Environmental or client-related barriers encountered
- How barriers were addressed
- Environmental modifications made
Client Response and Progress
- Engagement, motivation, attention, cooperation
- Notable successes or breakthroughs
- Difficulties or barriers to learning
- Responsiveness to prompts, reinforcement, and error correction
Skill Generalisation and Maintenance
- Evidence of generalisation across settings, materials, or people
- Maintenance of previously mastered skills
- Strategies used to promote generalisation
Caregiver Involvement (if applicable)
- Caregiver observations, questions, or concerns
- Informal coaching provided during session
- Caregiver’s implementation of strategies
Clinical Decisions and Modifications (if applicable)
- Modifications to procedures, prompting, reinforcement, or mastery criteria
- Rationale for changes
- Targets mastered, placed on maintenance, or discontinued
Risk Assessment
- Risk factors observed or discussed (self-harm, aggression, elopement, suicidal ideation)
- Protective factors
- Safety plans or action plans in place
Plan and Next Steps
- Therapist recommendations from today’s session
- Programming changes planned
- Areas for additional focus or senior clinician consultation
- Environmental modifications or material needs
- Preliminary plan for next session (programs and targets to prioritise)
- Date/time of next session
- Preparation needed for next session
Session Summary
- Overall productivity of the session
- Key highlights of client progress or challenges
- Primary focus moving forward
SECTION B: PARENT/CAREGIVER TRAINING SESSION
Session Information
- Date, start/end time, total duration
- Location, service type (Parent/Caregiver Training)
- Clinician name
- Caregiver name(s) and relationship to client
- Client name and age
- Whether client was present during training
Caregiver Presentation and Context
- Engagement level and receptiveness
- Concerns or questions raised at session start
- Emotional state and readiness to learn
Training Goals and Objectives
- Specific caregiver training goals being addressed
- Primary focus of today’s session
Topics Covered and Content Delivered
- ABA principles and techniques taught
- Specific topics covered (e.g., function of behaviour, token economy, visual schedules)
- Educational materials provided
- Use of real-life, family-relevant examples
Training Methods and Demonstrations
- Delivery methods used (explanation, modelling, role-play, in-vivo coaching, video, written materials)
- Specific techniques demonstrated by therapist
- Whether training was didactic, interactive, or experiential
Caregiver Practice and Implementation
- What the caregiver practised during the session
- Observable details of implementation
- Fidelity data (percentage of steps correct, prompts required)
Caregiver Performance Data
For each strategy practised:
- Strategy/skill name
- Implementation fidelity
- Areas of strength
- Areas for improvement
- Prompts/supports provided by clinician
Connection to Client Treatment Plan
- How training links to client’s current goals and programming
- Impact of caregiver implementation on client outcomes
Caregiver Understanding and Engagement
- Level of understanding of concepts taught
- Questions asked and answers provided
- Engagement and receptiveness to feedback
- Concerns, resistance, or barriers raised
- Confidence level for independent implementation
Caregiver Goals Progress
- Progress toward caregiver training goals in the treatment plan
- Whether goals were met, progressing, or require additional support
Barriers to Implementation
- Barriers identified (time, inconsistency, family demands, resources, emotional challenges)
- How barriers were addressed during the session
Problem-Solving and Collaboration
- Collaborative problem-solving that occurred
- Modifications made to increase feasibility for the family
- Caregiver contributions or insights
Home Practice Plan and Assignments
For each assignment:
- Strategy to practise
- Frequency/schedule
- Data collection required
- Materials provided
- Rationale and expected outcomes
- Caregiver concerns about completing assignments
Educational Materials and Resources Provided
- Handouts, worksheets, written instructions, video links, apps
- Language and comprehension level considerations
Clinical Observations and Reflections
- Quality of therapeutic relationship with caregiver
- Reflections on effectiveness of teaching methods
- Adjustments needed for future training sessions
Risk Assessment
- Risk factors discussed or observed
- Protective factors
- Safety plans or action plans
Next Steps
- Agenda for next parent/caregiver training session
- Goals to be targeted next
- Date/time of next training session
- Preparations needed
- Plan for following up on home practice
- Progress monitoring method
- Scheduled check-ins between sessions
- Coordination with other professionals
Session Summary
- What was taught and how the caregiver responded
- Key outcomes
- Focus for continued caregiver development
SECTION A: DIRECT THERAPY SESSION
Session Information
Date/Time: Tuesday, 15 July 2025, 9:00 AM – 10:00 AM (60 minutes)
Location: Client’s home
Service Type: 1:1 Direct ABA Therapy
Therapist: Jane Smith, Registered Behaviour Technician (RBT)
Client: Liam Brown, age 6
Caregiver Present: Yes – mother, Sarah Brown
Client Presentation
- Liam arrived in a positive mood with good affect and willingness to engage
- Mother reported he had slept well with no changes to medication or routine
- Engagement appeared slightly higher than the previous session, with Liam initiating eye contact with the therapist upon arrival
Programs and Targets Addressed
- Receptive Language: Following 2-step directions
- Manding: Requesting preferred items using PECS (Phase III)
- Self-Help: Independent handwashing – full task analysis
Session Activities and Teaching Procedures
- Session followed a structured rotation of table-based DTT and naturalistic environment teaching (NET)
- DTT used for receptive language targets in a distraction-minimised table setting, with massed and distributed trial formats
- NET embedded within a sensory play activity (kinetic sand) to target manding in a motivating context
- Handwashing practised in the bathroom using a visual task analysis prompt card
- Planned outdoor activity modified to an indoor gross motor activity due to rain, with no impact on session productivity
Data Collection Summary
- Program/Target: Receptive Language – Following 2-step directions
- Data Type: Trial-by-trial (10 trials)
- Performance Summary: 7/10 correct (70% accuracy)
- Prompt Level: Independent on 5 trials; gestural prompt on 2 trials; verbal + gestural on 3 trials
- Comparison to Previous Session: Improving (62% last session)
- Program/Target: Manding – Requesting preferred items via PECS Phase III
- Data Type: Frequency count
- Performance Summary: 6 independent mands across 20-minute NET block
- Prompt Level: No prompts required on 5 of 6 mands; 1 gestural prompt provided
- Comparison to Previous Session: Maintaining
- Program/Target: Self-Help – Handwashing task analysis (8 steps)
- Data Type: Percentage of steps completed independently
- Performance Summary: 5/8 steps independently (63%)
- Prompt Level: Physical guidance required on steps 3, 6, and 7 (soap application, rinsing, drying)
- Comparison to Previous Session: Improving (50% last session)
Prompting and Prompt Fading
- Least-to-most prompting hierarchy used across all programs
- For receptive language, therapist faded from verbal + gestural prompts to gestural-only prompts on 3 trials compared to last session
- Liam responded well to gestural prompts and did not require physical guidance for language targets
- For handwashing, physical guidance remains necessary for motor steps; fading to model prompts will be trialled next session for step 3
Reinforcement Strategies
- Token economy (5-token board) used throughout, with Liam exchanging tokens for 3-minute access to a preferred tablet game
- Continuous reinforcement (FR1) used during acquisition of new manding targets
- Fixed ratio schedule (FR3) used for receptive language targets
- Preferred edibles (small pieces of dried mango) incorporated as a backup reinforcer during handwashing
- Liam showed strong motivation throughout; no preference assessment conducted as current reinforcers remain highly effective
Challenging Behaviours
- No challenging behaviours were observed during this session
Barriers and Challenges
- Planned outdoor activity cancelled due to rain and replaced with an indoor gross motor activity
- Modification managed without difficulty and did not affect Liam’s engagement or session productivity
Client Response and Progress
- Liam was engaged and cooperative throughout the session
- Demonstrated strong motivation during NET activities and responded quickly to reinforcement
- Notable success: Liam independently initiated a mand for “sand” at the start of the play activity without prompting — the first spontaneous mand recorded outside of structured opportunities
- Attention sustained across the full session duration with no significant drops observed
Skill Generalisation and Maintenance
- Manding practised across two different activities (kinetic sand and a brief snack break), providing two-setting generalisation within the session
- Mother reported Liam used PECS at the dinner table on two occasions during the previous week, indicating emerging home generalisation
- No formal maintenance probes conducted this session
Caregiver Involvement
- Sarah observed the NET manding activity and participated under therapist guidance during the final 10 minutes
- Coached on prompt delivery and reinforcement timing; demonstrated correct implementation on 4 of 5 opportunities
- Sarah raised a question about responding when Liam grabs items without using PECS; therapist provided guidance on implementing an errorless correction procedure at home
Clinical Decisions and Modifications
- Receptive 1-step direction target formally mastered (above 80% across three consecutive sessions) and moved to monthly maintenance schedule
- 2-step direction target introduced this session as the next step in the receptive language program
- Mastery criterion for new target set at 80% across three consecutive sessions
Risk Assessment
- No risk factors were identified or observed during this session
Plan and Next Steps
- Continue receptive language program with 2-step directions; aim to fade gestural prompts to independent responding
- Trial model prompt fading for handwashing step 3 next session
- Prepare visual prompt card for home handwashing practice to support caregiver implementation
- Senior clinician to review manding program at next supervision given emerging spontaneous manding
- Next session: Wednesday, 23 July 2025, 9:00 AM at client’s home
Session Summary
Liam demonstrated measurable progress across receptive language and self-help targets, and a notable first spontaneous mand was recorded in a naturalistic context. The 1-step direction target was formally mastered and the program advanced. Upcoming focus will be on prompt fading for the 2-step direction and handwashing targets, and supporting caregiver implementation of manding procedures at home.
