The assessment is organized into structured clinical sections. Each section groups related questions and maps to a specific domain of the behavioral evaluation. The platform supports a wide range of question types to capture all forms of clinical information accurately.
Clinical Sections
The assessment covers the following clinical domains. Each corresponds to a dedicated section in the form:
| Section | What It Captures |
|---|---|
| Parent / Guardian Information | Contact details, relationship to client, consent |
| Developmental History | Birth history, early development milestones |
| Sleep & Health | Sleep patterns, medical conditions, physical health |
| Mental Health History | Prior diagnoses, therapy history, psychiatric evaluations |
| Therapy & Education | School placement, current and past therapy services |
| Language & Communication | Expressive and receptive language, AAC use |
| Daily Living Skills | Self-care, hygiene, dressing, toileting, home chores |
| Cognitive & Academic Skills | Literacy, numeracy, cognitive function |
| Social Interaction | Social skills, play, emotional regulation |
| Medical Conditions & Treatment | Diagnoses, medications, medical history |
| Maladaptive Behaviors | Behavior description, intensity, frequency, baseline data (repeatable) |
| Replacement Programs | Replacement behavior goals linked to maladaptive behaviors (repeatable) |
| Intervention Planning | Goals, strategies, service implementation details |
| Diagnostic Information | ICD-10-CM codes, clinical impressions |
Sections marked as repeatable can be completed multiple times within a single assessment — once per behavior or program being documented.
Question Types
The platform supports fifteen distinct question types, each designed to collect a specific category of clinical information.
Text Input
A single-line field for short answers such as names, dates of birth, phone numbers, or brief factual responses.
Number Input
A numeric field for quantities such as age, number of sessions per week, or frequency counts.
Date Input
A date picker for recording specific dates — diagnosis dates, service start dates, birth dates.
Yes / No
A simple binary response. Some yes/no questions conditionally require an explanation when answered one way (e.g., “Does the client have a history of self-injury?” answered Yes may require elaboration).
Single Option
A dropdown or radio button selection where exactly one answer must be chosen from a predefined list.
Single Option (Editable)
Same as single option, but includes an “Other” field that allows the clinician to enter a custom response not covered by the preset options.
Multiple Options
A checkbox group where one or more answers can be selected from a predefined list.
Multiple Options (Editable)
Same as multiple options, with an “Other” field for custom entries.
Text Area
A multi-line free-text field for longer narrative responses — clinical observations, background history, or descriptive notes.
Rich Text Editor
A formatted text editor supporting bold, italic, lists, and other basic formatting. Used for sections where the clinician writes detailed clinical descriptions that will appear verbatim in the report. The editor optionally includes an AI-assisted review feature that analyzes the entered text and offers improvement suggestions.
File Upload
Allows attachment of supporting clinical documents, images, or charts (JPEG, PNG, PDF; max 3 MB). Uploaded files are stored securely and can be embedded in the generated report.
Address Picker
A structured address input that captures street, city, state, and zip code in a consistent format.
Multiselect List
A searchable list from which multiple items can be selected and organized. Used for ICD-10-CM diagnostic code selection, allowing the clinician to search the full federal code database and select applicable codes.
Baseline Graph
A specialized input for documenting behavioral baseline data. The clinician can either:
- Build a graph by entering behavioral observation data points (date and value pairs) — the platform generates a visual baseline graph automatically
- Upload a graph as an image file if one already exists
The generated or uploaded graph is embedded in the final Word report.
Data Table
A structured table with configurable rows and columns. Used to organize comparative or multi-variable data that needs to appear in tabular format in the report.
Question Options and Hints
Each question may include:
- Hint text — a brief clarification displayed near the question to guide the clinician’s response
- Instructions — more detailed guidance that can be expanded when needed
- Explanation field — some questions require or offer an optional explanation field alongside the main answer. Explanation requirements vary by question:
– Always required – Optional – Required only when the answer is “Yes” – Required only when the answer is “No” – Disabled (no explanation possible)
ICD-10-CM Diagnostic Codes
The platform includes the complete ICD-10-CM federal diagnostic code database, updated annually. In the diagnostic section, clinicians can:
- Search for codes by description or code number
- Select multiple applicable codes
- Have codes automatically suggested based on assessment context
Selected codes appear in the final report in the appropriate diagnostic section.
