ABA Risk Assessment Form

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Simply fill out the form below for a premium indication! Feel free to give us a call at 408 510 5801 if you’d like to talk through the application process.

- Step 1 of 6

General Information

Applicant Name *

Applicant Job Title *

Business Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Website Address *

When was the business started? *

FEIN# *

Type of Business (LLC, Corp, Partnership, etc.) *

Contact Phone # *

Contact Email Address *

Are you a member of CalABA? *

Are you BHCOE accredited? *

General Business Information

Estimated Annual Revenue *

Estimated Annual Payroll *

Total Number of Clients *

Total Number of Employees *

Training Information

Do you provide any of the following training programs? (Select all that apply.) *

De-Escalation Training
Formal Training to Staff
Abuse Prevention Program
Employee Handbook
Parent Required

ABA Program Information

Do you provide any of the following Behavioral Health Services? (Select all that apply.) *

Autism
Crisis Stabilization
Daycare
Depression
Family Therapy
Home Based
Parent Training
Personality Disorders
Post-Traumatic Stress
Public Clinic
Private School
Public School

Please provide the number of 1-5 yr. old clients. *

Please provide the number of 6-12 yr. old clients. *

Please provide the number of teenage clients. *

Please provide the number of adult clients. *

What percentage of your clients receive services at home? *

What percentage of your clients receive services at a community center? *

What percentage of your clients receive services at a public or private school? *

What percentage of your clients receive services at a clinic/other location? *

For home-based programs, does your intake process involve questions on the following? (Please select all that apply.) *

Physical Inspection
Siblings in the Home
Family in the Home
Weapons/Guns
Overall Housekeeping
Unique Characteristics
Parking Information
Dogs/Pets
Access Information
General Safety
DOES NOT APPLY

Employment Information

Which of the following checks are performed on prospective employees? *

Motor Vehicle Records
Personal Auto Insurance Requirement
Driver Safety Program
Criminal Background
Sexual Abuse Registry
Reference/Work History

Do you have any staff members in the following roles? (Please check all that apply.) *

Behavioral Therapists
Board Certified Behavior Analysts
Psychiatrists
Psychologists
Therapists
Social Workers (BSW)
Social Workers (MSW)
Teachers/Tutors/Aides

Have you hired any independent contractors? *

What role(s) are your independent contractors? (Please check all that apply.)

Behavioral Therapists
Board Certified Behavior Analysts
Psychiatrists
Psychologists
Therapists
Social Workers (BSW)
Social Workers (MSW)
Teachers/Tutors/Aides

How many staff members are full-time behavioral therapists?

How many staff members are part-time behavioral therapists?

How many staff members are full-time Board Certified Behavior Analysts?

How many staff members are part-time Board Certified Behavior Analysts?

How many staff members are full-time Psychiatrists?

How many staff members are part-time Psychiatrists?

How many staff members are full-time Psychologists?

How many staff members are part-time Psychologists?

How many staff members are full-time Therapists (Physical/Occupational)?

How many staff members are part-time Therapists (Physical/Occupational)?

How many staff members are full-time Social Workers (BSW)?

How many staff members are part-time Social Workers (BSW)?

How many staff members are full-time Social Workers (MSW)?

How many staff members are part-time Social Workers (MSW)?

How many staff members are full-time Teachers/Tutors/Aides?

How many staff members are part-time Teachers/Tutors/Aides?

How many contractors are full-time behavioral therapists?

How many contractors are part-time behavioral therapists?

How many contractors are full-time Board Certified Behavior Analysts?

How many contractors are part-time Board Certified Behavior Analysts?

How many contractors are full-time Psychiatrists?

How many contractors are part-time Psychiatrists?

How many contractors are full-time Psychologists?

How many contractors are part-time Psychologists?

How many contractors are full-time Therapists (Physical/Occupational)?

How many contractors are part-time Therapists (Physical/Occupational)?

How many contractors are full-time Social Workers (BSW)?

How many contractors are part-time Social Workers (BSW)?

How many contractors are full-time Social Workers (MSW)?

How many contractors are part-time Social Workers (MSW)?

How many contractors are full-time Teachers/Tutors/Aides?

How many contractors are part-time Teachers/Tutors/Aides?

Are there other employees or contractors that aren't listed above? (Please note the number, employment type, part- or full-time status, and job titles.) *

Abuse / Molestation

Do you have any of the following policies or procedures in place for dealing with abuse/molestation? (Please select all that apply.)

Written procedures for dealing with physical and sexual abuse
Supervision plan that monitors staff in day-to-day relationships with clients
Procedures in place to avoid one-on-one situations with clients
Documented staff training on recognizing and reporting physical/sexual abuse

Property

Do you have a physical location requiring coverage? *

Full Address

Approximate Square Footage

Ownership Status

Leased
Owned

Does your building have the following features? (Please select all that apply.)

Fire Sprinklers
Alarm System

Number of Stories

Approximate Age of Building

Type of Construction (Wood Frame, Concrete, Etc.)

Value of Business Property to Insure (Replacement Cost Valuation)

Value of Building to Insure (Replacement Cost Valuation)

Current Insurance Information

Current Policy - General Liability

Do you currently have general liability insurance? *

Name of Current General Liability Company

General Liability Limits

General Liability Expiration Date

General Liability Annual Premium

Have you had any general liability claims in the past 5 years?

If yes, please explain:

Current Policy - Automobile Liability

Do You currently have automobile liability insurance?

Name of Current Automobile Liability Company

Automobile Liability Limits

Automobile Liability Expiration Date

Automobile Liability Annual Premium

Have you had any automobile claims in the past 5 years?

If yes, please explain:

Current Policy - Professional Liability

Do you currently have professional liability insurance? *

Name of Current Professional Liability Company

Professional Liability Limits

Professional Liability Expiration Date

Professional Liability Annual Premium

Have you had any professional liability claims in the past 5 years?

If yes, please explain:

Current Policy - Abuse/Molestation Liability

Do you currently have abuse/molestation liability insurance?

Name of Current Abuse/Molestation Liability Company

Abuse/Molestation Liability Limits

Abuse/Molestation Liability Expiration Date

Abuse/Molestation Liability Annual Premium

Have you had any abuse/molestation claims in the past 5 years?

If yes, please explain:

Comment

Liberty Behavioral Health

CA LIC #0D79653 – LICENSED IN ALL 50 STATES

1122 Meridian Ave. San Jose, CA 95125

ABA Risk Assessment Form

Ready to Get Started?

General Information

General Business Information

Training Information

ABA Program Information

Employment Information

Abuse / Molestation

Property

Current Insurance Information

Current Policy - General Liability

Current Policy - Automobile Liability

Current Policy - Professional Liability

Current Policy - Abuse/Molestation Liability

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