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Functional Behavioral Assessment (FBA)
A Team Approach to Understanding Behaviors and Prescribing Interventions
Student: ID#:DOB: Grade:Teachers:Family:Family:Phone:
Email: Planning Meeting Date:Follow-up Meeting Date:
Team Members:Parent:Teacher:Student:Other: Intervention Facilitator:Other:Mental Health:Other:
Sources of Information:
Indicate all that apply by listing date that information was obtained:
____ Behavior Checklists ____ Behavioral Observations ____ Record Review
____ Student Interview ____ Parent Interview ____ Teacher Interview
____ Academic Assessment ____ Other: ____ Other:
Assessing Thinking Skills:
Executive Functioning SkillStrengthDeficitHandling transitions, shifting from one mindset/task to another (shifting cognitive sets)
Example:Sticking with tasks requiring sustained attention (perseverance)
Example:Doing things in a logical sequence or prescribed order (organization)
Example:Reflecting on multiple thoughts or ideas simultaneously (working memory)
Example:Maintaining focus for goal-directed activities (sustained attention/concentration)
Example:Thinking before responding, considering the likely consequences of actions (reflective)
Example:Responding to the concept of time
Example:Language Processing SkillsStrengthDeficitExpressing concerns, needs, or thoughts in words (expressive language)
Example:Identifying or articulation whats bothering you
Example:Understanding what is being said (receptive language)
Example:Emotional Regulation SkillsStrengthDeficitManaging emotional response to frustration so as to think rationally (separation of affect)
Example:Managing irritability and/or anxiety on a chronic basis (outside the context of frustration)
Example:Cognitive Flexibility SkillsStrengthDeficitSeeing the grays, being comfortable with iffy thinking (versus need for precision, literal)
Example:Thinking hypothetically or Inferentially (using hypothesis testing)
Example:Handling deviations of the rules, routines, original plan (flexible, manages changes well)
Example:Handling unpredictability, ambiguity, uncertainty, novelty (flexible, compensates, rethinks)
Example:Shifting from original idea or solution/adapted to changes in plan or new rules
Example:Taking into account situational factors that would suggest the need to adults a plan of action
Example:Interpreting information accurately/avoiding cognitive distortions or biases in thinking such as over-generalizing personalizing
Example:Social SkillsStrengthDeficitAttending to and/or accurately interpreting social cues and nuances
Example:Starting conversations, entering groups, being reciprocal, sharing
Example:Seeking attention in appropriate ways
Example:Appreciating how ones behavior affects other people (Theory of Mind)
Example:Empathizing with others, appreciating another persons perspective or point of view (TOM)
Example:Appreciating how one is coming across or being perceived by others
Example:
Academic Skill Profile: (See Profile Web)
StrengthDeficitMathematical Concepts (vocabulary, decomposing/composing, organizing, problem solving)Mathematical Calculation (1-3, to 10, to 20, to 100)Sound Knowledge and Manipulation (Phonemic Awareness and Phonics) Decoding/EncodingSight Word KnowledgeReading Comprehension (Concrete Knowledge, Inferential, Perspective taking)Reading FluencySpellingWritingPenmanshipScience
Student Profile (Use checklist and observations/interviews/assessments to consider strengths):
STRENGTHS: (Identify at least 3 strengths)
1.
2.
3.
4.
WEAKNESSES:
1.
2.
3.
4.
Description of the behavior(s) of concern defined in specific, observable, measurable terms:
BEHAVIOR
(Specific, observable, measurable)
Frequency, Duration, IntensityDATE OF ONSETANTECEDENT
Trigger to Behavior
Problem to be SolvedHYPOTHESIZED
THINKING SKILL DEFICITOCCURS MOST
Who, what
WhereOCCURS LEAST
Who, what
Wherea.b.c.d.
BEHAVIOR COLLECTION
(Specific, observable, measurable)
Frequency, Duration, IntensityDATE
OF
COLLECTIONFREQUENCY
How man times per
__.DURATION
How long behavior lasts?INTENSITY Level of Force or ConcernFACTORS
Location
Peers
Schedulea.b.c.d.
Previous Accommodations/Interventions:
What accommodations/interventions have been tried?Effectiveness/results with measurable data points
Hypothesis. Why does the behavior(s) occur? What is the students motivation/outcome?
FORMCHECKBOX Attention FORMCHECKBOX Power / Control FORMCHECKBOX Approval of Others / Acceptance / Affiliation FORMCHECKBOX Justice / Revenge FORMCHECKBOX Gain Access to Objects or Activities FORMCHECKBOX Escape / Avoidance of a Task or an Event FORMCHECKBOX Self-Gratification / Sensory Stimulation FORMCHECKBOX Escape / Avoidance of Attention FORMCHECKBOX Protection FORMCHECKBOX Communicate Feelings FORMCHECKBOX Why is the student unable to achieve this outcome in a more adaptive manner? In other words: What skills are lacking? FORMCHECKBOX Specific skill deficits within each domain: FORMCHECKBOX Executive Functioning Skills FORMCHECKBOX Language Processing Skills FORMCHECKBOX Emotional Regulation Skills FORMCHECKBOX Cognitive Flexibility Skills FORMCHECKBOX Social Skills FORMCHECKBOX Other:
Explain the hypothesis:
Working Hypothesis statement 1:
Top of Form
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Working Hypothesis statement 2:
Top of Form
When (Describe environmental demand) PRIVATE "" MACROBUTTON HTMLDirect is expected, the student (describe behavior(s) of concern) PRIVATE "" MACROBUTTON HTMLDirect because of a deficit in (describe the specific skill deficit(s)) PRIVATE "" MACROBUTTON HTMLDirect , PRIVATE "" MACROBUTTON HTMLDirect , and PRIVATE "" MACROBUTTON HTMLDirect .
Bottom of Form
BEHAVIOR INTERVENTION PLAN
A Team Approach to Understanding Behaviors and Prescribing Interventions
Replacement Skill Instruction/environmental supports: What specific problems will be solved with the student in order to build better problem solving skills, frustration tolerance, and/or flexibility/adaptability? What specific expectations will not be pursued at this time in order to reduce challenging behaviors?
High priority problems to be solved (be specific):
1)
2)
Unmet expectations to be addressed later (be specific):
1)
2)
3)
What supplemental direct skills instruction (if any) will be provided (by whom, how often, etc.)?
1)
2)
3)
Crisis Intervention Plan (if applicable): Follow school or district safety plan. If the student demonstrates behaviors that are unsafe to self or others, how will the team respond? If restraint is part of this plan staff must have current CPI training and a signed Parent Permission for Restraint form should be attached.
The following positive behavioral interventions will take place to help the student deescalate from a crisis
(Include behaviors, redirection strategies, and de-escalation strategies):
1.
2.
3.
4.
5.
Communication/Coordination:
COMMUNCIATION PLAN (include staff to be notified of plan, how contact will be made, date/frequency to be completed, and provide copy of plan to parent)
Review Date:
Outcome/Evaluation: Monitor progress through the Problem-Solving Process and adjust FBA/BIP as needed based on data (see Progress Monitoring Document).
DateIntervention Plan DetailsEffectiveness/results with measurable data points
Next Steps
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Adapted Think Kids, 2014, Stefanini
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