Have you completed this form previously and need to upload documents?
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Yes
No
Please upload your document(s) here. The autism (ASD) evaluation and diagnostic report is required to move forward in the intake process. This must be an official autism diagnostic report (e.g., ADOS, CARS) and not just a narrative summary from the provider.
Our team will reach out about next steps once this document is received. Additional (optional) documents that are helpful and you may be asked to provide at a later time include: 1. CSH-RUCARES Intake Packet.pdf 2. A photo or copy of your child's insurance card (front and back) 3. A copy of your child's most recent IEP 4. Any prior behavior reports or ABA documentation
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The Severe Behavior Program at Children's Specialized Hospital-Rutgers University Center for Autism Research, Education, and Services (CSH-RUCARES) provides comprehensive and specialized services for children and adolescents with autism spectrum disorder who engage in behavior, such as aggression, self-injury, and property destruction. Such behavior may pose risks to themselves or others, disrupt their environments, and/or significantly impact their or their families' quality of life. Our general approach to assessment and treatment involves: 1. Conducting assessments to identify why destructive behavior occurs. 2. Designing an individualized treatment plan to reduce destructive behavior and teach appropriate skills. 3. Ensuring strategies are effective across environments (e.g., home, school) by actively working with caregivers, teachers, and other key stakeholders. Common referral concerns include: • Aggression towards others • Self-injurious behavior • Property destruction • Pica (eating non-food items) • Elopement (running away) • Non-cooperation with daily activities • Tantrums Our programs are rooted in applied behavior analysis (ABA) and emphasize safety, relapse prevention, and long-term success. Our state-of-the-art facility is equipped with highly trained staff and the expertise needed to address severe behavior effectively, while ensuring the child's and family's wellbeing. Note: Although we use a behavior-analytic treatment approach, CSH-RUCARES does not offer early-intensive behavioral intervention often called "ABA" or "applied behavior analysis." If you are interested in general skill building and management of less intense behavior (e.g., repetitive motor movements or speech), please consult your insurance company to determine eligible services in your area. To determine whether your child is appropriate for one of our programs, please complete the screening questionnaire below. We look forward to the possibility of working with you and your family! This program addresses severe destructive behavior that poses safety risks, disrupts daily routines, and cannot be effectively managed through less-intensive programs or medication. During clinic visits, your child will work with a team that includes two to three paraprofessional technicians, a Board Certified Behavior Analyst (BCBA), and oversight from a licensed psychologist (LP) and/or doctoral-level BCBA (BCBA-D). The team will identify factors contributing to the destructive behavior and develop an effective treatment plan to be implemented at home, school, and in the community. A BCBA will provide hourly training to caregivers once per week during the first half of the admission and then conduct home, school, and community visits in the latter stages of the admission by having the caregivers implement the treatment for most of the appointment in those settings as the behavior analyst provides coaching and support. Clinic visits occur for 3 or 6 hours per day, 5 days per week, and are planned to occur across 16 consecutive weeks. However, some individuals may benefit from an extended admission. The BIF program focuses on collaborating with caregivers to teach them practical skills and strategies to manage and reduce their child's challenging behavior effectively. During clinic visits, a BCBA or BCBA-D will work individually with the primary caregiver to help them identify individualized strategies for preventing and managing challenging behavior that work best for them and their child. The BCBA or BCBA-D will coach the primary caregiver through implementing these strategies with their child. The program incorporates information from the assessment phase into the Research Units in Behavioral Intervention (RUBI; https://www.rubinetwork.org ) model, which is an evidence-based caregiver training approach. Clinic visits will initially occur for 2 hours per day, 2 days per week for the first 3 weeks to complete functional behavior assessments. Following the initial assessment period, clinic visits occur for 1-1.5 hours per day, 1 day per week, for approximately 28 consecutive weeks.
Child's First and Last Name
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Child's Date of Birth (DD/MM/YYYY)
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Person completing this form
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Caregiver/legal guardian
Teacher
Case worker
Other
If you selected "other," please specify your relation to the child
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First and Last Name of person completing this form
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Email address
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Phone number
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May we text this phone number as part of follow-up (e.g., reminders to complete intake packet)?
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Yes
No
Answering "No" will not affect your child's eligibility for our clinical program.
What is your preferred mode of communication?
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Email Text message Telephone call
Are you interested in being contacted regarding research opportunities that may be relevant to your child (e.g., evaluation of a new behavioral therapy or drug trial)?
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Yes
No
Answering "No" will not affect your child's eligibility for our clinical program.
Some research studies evaluate sibling risk and interactions. If you answered "Yes" to being contacted about research, please indicate whether your child has any siblings and, if so, their ages. Some studies evaluate newborn behavior; if the mother of the referred child is expecting, please indicate.
There is an ongoing study evaluating the use of Propranolol, a medication being investigated for the management of challenging behavior, with promising preliminary results.
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Yes
No
Does your child have a diagnosis of autism?
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Yes
No
Please provide your insurance carrier (e.g., Horizon BCBS) and the plan type or name (e.g., OMNIA plan).
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PICA involves the repetitive and persistent ingestion of inedible items (i.e., items that should not be eaten) such as bark, bugs, cigarette butts, clothing, coins, dirt, food dropped on the floor or ground, grass, leaves, paint chips, pet hair, etc.
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Does your child engage in any forms of challenging behavior that were not mentioned in the previous question(s)
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If you selected "Other" on the previous question, please specify the behavior(s) here.
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Please indicate the severity of your child's injury risk behavior (select all that apply):
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Level 1: Injury risk behavior resulting in no: (a) marks on body, (b) burns, (c) gagging, (d) vomiting, (e) choking; or (f) running away from caregivers, within sight and easily retrieved.
Level 2: Injury risk behavior resulting in: (a) reddening of skin or mild swelling; (b) a 1st degree burn; (c) mild gagging; or (d) running away from caregivers, out of sight but easily retrieved.
Level 3: Injury risk behavior resulting in: (a) light scratches, small or shallow breaks in skin, moderate to severe swelling; (b) a 2nd degree burn; (c) vomiting or significant choking; or (d) running away from caregivers, out of sight and difficult to retrieve.
Level 4: Injury risk behavior resulting in: (a) scars, lasting tissue damage, disfigurement; (b) a 3rd degree burn; (c) poisoning; (d) loss of consciousness; or (e) running away from caregivers warranting involvement of law enforcement.
Please indicate the severity of your child's aggression (select all that apply):
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Please indicate the severity of your child's property destruction (select all that apply):
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Level 1: Property Destruction resulting in disruption of property but no permanent damage to paper items, toys, teaching materials, furniture, vehicles or buildings.
Level 2: Property Destruction resulting in damage to paper items or other light objects.
Level 3: Property Destruction resulting in (a) breakage of pencils, plastic toys, glassware, or other breakable items, and/or (b) scratches or permanent marks on furniture, walls, cars, etc.
Level 4: Property Destruction resulting in structural damage to furniture, cars, walls, etc.
Please indicate the severity of your child's self-injurious behavior ([SIB] select all that apply):
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Please indicate the severity of your child's pica (select all that apply):
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Level 1: Pica not involving any of the following: (a) solid items larger than 1/2 inch in diameter (e.g., coins, large buttons), (b) sharp items (e.g., pins, staples), (c) contaminated items (e.g., items from garbage can or ash tray, paint chips), or (d) toxic or poisonous items (e.g., medicines, glue).
Level 2: Pica involving (a) solid items larger than 1/2 inch in diameter (e.g., coins, large buttons), but not sharp, contaminated, or toxic or poisonous items.
Level 3: Pica involving sharp, contaminated, or toxic or poisonous items, but not requiring emergency medical attention (e.g., called physician for advice).
Level 4: Pica involving sharp, contaminated, or toxic or poisonous items and requiring emergency medical attention.
Please indicate the severity of your child's disruptive behavior (select all that apply):
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If you have any images (e.g., photos of tissue/property damage), documents (e.g., copy of law-enforcement report) , or short videos (e.g., 1-min clip of your child's problem behavior) that would highlight the severity of your child's problem behavior, please upload those files here.
Can you provide or arrange for consistent transportation to our clinic in Somerset (888 Easton Ave, Somerset, NJ) up to five days per week (Monday-Friday)?
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Yes
No
Has your child received:
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Yes, has received 3 months of outpatient therapy and medication intervention
No, has not received 3 months of outpatient therapy and/or medication intervention
You indicated that you are unable to provide, or arrange for, regular transportation to our clinic in Somerset.
Based on the information you provided, your child might be appropriate for one or more of our programs at CSH-RUCARES. Additional documentation is required to move forward with the intake process.
Please upload your document(s) here. The autism (ASD) evaluation and diagnostic report is required to move forward in the intake process. This must be an official autism diagnostic report (e.g., ADOS, CARS) and not just a narrative summary from the provider.
Our team will reach out about next steps once this document is received. Additional (optional) documents that are helpful and you might be asked to provide at a later time include: 1. CSH-RUCARES Intake Packet.pdf 2. A photo or copy of your child's insurance card (front and back) 3. A copy of your child's most recent IEP 4. Any prior behavior reports or ABA documentation
If you need more time to obtain the required documenation, you can complete the screener now and return at a later time to upload it here. As a reminder, our team will reach out once the required documentation is received.
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As you wait to hear from us regarding your child's eligibility for our program, please see the attached "Resources for Caregivers" file for additional opportunities in your area for you or your child.