Functional Behavior Assessment

Functional Behavior Assessment
Client Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Sex
FemaleMale
Date Completed
MonthDayYear
Date
Primary Caretakers ( Please list the family members, teachers, or other individuals who care for your child on a regular basis)
Name1 Relationship 2
Name     3 Relationship4
Name5 Relationship6
Name7 Relationship   8
Name   9   Relationship   10
Name11 Relationship 12
Living Arrangement: Please describe your home and community:
Programs/Services: Please list the educational or therapeutic programs( eg., school, day care, OT, PT, seech) in which your child currently participating. Provide contact person and frequency.
Broad Goals:
Medical Issues: Describe prenatal and perinatal events, along with a complete developmental history (physical, psychological, social, intellectual, and academic)
Please list any medical, psychological, psychiatric diagnoses that your child has received including any previous or current infectious diseases.
Please list any medications your child is taking that could impact his/her behavior: Medication, Dose, Frequency, Reason, Impact/Side effects
Please describe any additional medical complications (e.g, asthma, allergies, skin conditions, stomach problems, seizures, substance abuse) that could be affecting your child's behavior.
Does he or she have a primary care physician?
YesNoNot sure
Primary Care Physician Information (Name, Specialty)
About how many hours of sleep does your child get each day (including naps)?
Does he or she sleep through the night?
YesNo
Doe your child have any eating habits or dietary restrictions that could affect this or her behavior? If so, please describe.
Is your child currently experiencing homicidal or suicidal ideations? (If yes, then 1-refer for immediate evaluation by an appropriate psychiatric professional, or 2- call 911, depending on the level of risk).
Has your child been a victim of abuse of any kind? Has your child been a perpetrator of abuse of any kind? If yes for either of the above, please describe.
(For teens, 12 and older) If an appropriate, please explain any sexual history behavior:
Are you aware of any past or current substance abuse your teen may have engaged in including the use of nicotine and alcohol? Please describe
Has any substance abuse screening occurred? No or Yes
Pertinent Family History: Please describe any relevant medical family history (e.g., sibling/caregiver's psychological diagnosis, medical conditions, medications/treatments, substance abuse, etc.) that could affect your child's behavior, treatment implementation, and/or the participation of team members.
Please describe any relevant behavioral family history (e.g, sibling/caregiver's behavioral diagnoses, criminal history, behavioral history, treatments, etc.) that could affect your child's behavior, treatment implementation, and/or the participation of team members.
Please describe any relevant spiritual variables (e.g., family beliefs, perspectives, rituals, observations, traditions, etc.) that could affect your child's behavior, treatment implementation and/or the participation of team members.
Describe any legal or marital issues that may impact the implementation of services (e.g., divorce, guardianship, custody issues, etc.)
Are currently receiving behavioral health services from another provider? No or Yes
Have you ever received behavioral health services (ABA) in the past? No or Yes? If yes, what was the approximate ranges of dates you saw that provider for? Who was the provider? What were your child's responses to the treatment provided (e.g., what worked, and what didn't work?
Child's Strengths: What are your child's greatest strengths (e.g., skills, interests)?
Communication Skills: How does your child communicate his or her needs (please check all that apply? Words, gestures or other form of communication used:
Request Attention
Ask for assistance
Request toy/object
Initiate activity
Avoid a situation
Take a break/stop
Say "no" to request
Indicate comfort
Other skills: Describe your child's ability to perform the following types of skills. Self-care (e.g., dressing, toileting), Daily living (e.g., household chores), Play/leisure (e.g., using toys, games), Academics (e.g., writing, cutting).
Receptive Communication: Give examples of the ways in which your child responds. Requests or instructions followed. Behavior imitated.
Potential Reinforcers: What does your child like (e.g., if presented with a variety of options or given free time, what would your child choose)?
Attention
ConversationEye contactTouchOther
Tangibles
ActivitiesToysOther
Sensations
SmellsSightsTouchOther
Behaviors of Concern: What does your child say or do that concerns you most (e.g., aggression toward self or others, property destruction, tantrums, screaming, inappropriate interactions, resistance, off-task behavior, substance abuse, sexual behavior)? Estimate how often, how long, how severe.
1. Behavior
BehaviorDescription
Frequency
HourlyDailyWeeklyOther
Severity
HighMediumLow
Duration: (seconds, minutes, hours)
2. Behavior
BehaviorDescription
Frequency
HourlyDailyWeeklyOther
Severity
HighMediumLow
Duration: (seconds, minutes, hours)
3. Behavior
BehaviorDescription
Frequency
HourlyDailyWeeklyOther
Severity
HighMediumLow
Duration: (seconds, minutes, hours)
4. Behavior
BehaviorDescription
Frequency
HourlyDailyWeeklyOther
Severity
HighMediumLow
Duration: (seconds, minutes, hours)
5. Behavior
Behavior Description
Frequency
HourlyDailyWeeklyOther
Severity
HighMediumLow
Duration: (seconds, minutes, hours)
Which, if any of these occur together?
In what environments do these behaviors occur?
HomeSchoolCommunityOther
Impact of Behavior: How are your child's behaviors affecting your child's development, or participation in activities or settings? What is the impact on your family?
Previous Interventions.
Please list strategies and interventions you have tried or other providers have attempted in order to address your child's behavior, when they were used, and their impact (i.e., how they worked)
Interventions Attempted, Whom, When, Impact on Behavior:
Extracurricular activities: Please describe any extra-curricular activities or community resources that your child is involved with:
List activities in which your child has most successful and those in which your child has the greatest difficulty.
Most Successful
Most Problematic
Is your child's daily schedule consistent (i.e Do meals, bedtimes, and other daily events occur at the same time and in the same order)?
YesNoOther
Do you feel that your child generally knows what is going to happen (e.g, where the child will be going, when, and with whom?
YesNoNot sure
Opportunities for choice: Please describe the different types of choices you child has the opportunity to make on a regular basis (e.g., what to wear, with whom to play, what activities to do):
Social Influence: With whom is your child's behavior of concern...
Most LikelyLeast Likely

Possible Triggers: What impact would you expect the following situations to have on your child's behaviors of concern?

	Most likely	No impact	Less likely
Asked to do a difficult task
Told no or to stop an activity
Attention is withdrawn
Change in routine/schedule
Loud or chaotic situations
Required to wait/delayed

Other situations that are particularly difficult:
Possible Functions: What are the most common outcomes of your child's behaviors of concern (e.g., does your child get attention or items, avoid demands or situations?
1. Behavior
What does your child get?What does your child avoid?
2. Behavior
What does your child get?What does your child avoid?
3. Behavior
What does your child get?What does your child avoid?
4. Behavior
What does your child get?What does your child avoid?
5. Behavior
What does your child get?What does your child avoid?
Other Issues: Please feel free to describe other issues you feel could be influencing your child's behavior.
Should be Empty: