Functional Behavior Assessment

Client Name

First NameLast Name

Date of Birth

Date

Sex

Date Completed

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?

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?

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

Other

Tangibles

Other

Sensations

Other

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

Other

Severity

Duration: (seconds, minutes, hours)

2. Behavior

BehaviorDescription

Frequency

Other

Severity

Duration: (seconds, minutes, hours)

3. Behavior

BehaviorDescription

Frequency

Other

Severity

Duration: (seconds, minutes, hours)

4. Behavior

BehaviorDescription

Frequency

Other

Severity

Duration: (seconds, minutes, hours)

5. Behavior

Behavior Description

Frequency

Other

Severity

Duration: (seconds, minutes, hours)

Which, if any of these occur together?

In what environments do these behaviors occur?

Other

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)?

Other

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?

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?

Rows	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