ABA Barriers Assessment Questionnaire
Use this form to identify barriers that may be affecting ABA participation and access.
Respondent Information
Respondent's Name
*
First Name
Last Name
Relationship to the Individual Receiving ABA Services
*
Parent
Caregiver
Guardian
Self
Other
Primary Contact Email
*
example@example.com
ABA Barriers Assessment
Overall access difficulty
*
Low difficulty
1
2
3
4
5
6
7
8
9
High difficulty
10
1 is Low difficulty, 10 is High difficulty
Barrier areas
*
Rows
No barrier
Mild
Moderate
Severe
Scheduling
1
2
3
4
Transportation
5
6
7
8
Cost
9
10
11
12
Staffing/availability
13
14
15
16
Time constraints
17
18
19
20
Communication challenges
21
22
23
24
Understanding the process
25
26
27
28
Family/school coordination
29
30
31
32
Top barrier areas
*
Scheduling
Transportation
Cost
Staffing/availability
Time constraints
Communication challenges
Understanding the process
Family/school coordination
Other
Brief description of main barriers
Follow-up and Notes
Additional context or examples
Preferred follow-up method
Phone
Email
Text message
No follow-up needed
Submit
Should be Empty: