rev 6.22.2016
Thank you for contacting the Severe Behavior Disorders Research Clinic!
We work with individuals of all ages and any diagnosis who engage in problem behavior, such as self- injurious behavior, aggression, property destruction, noncompliance, stereotypy, elopement, and tantrums.
If you are interested in services for the assessment and treatment of problem behavior, your child will be added to the waiting list as soon as you send this initial questionnaire (below) to us at [email protected] or FAX it to 281-283-3510 with attention to Dr. Fritz. (You will not be on the waiting list until we receive the completed document.)
Our waiting list can be as long as 0-12 months.
We have a variety of research projects in progress at all times and some families might qualify to participate.
Our standard cost for services is $50/hour, and we offer a reduced rate for eligible families.
Unfortunately, we are not able to bill insurance companies directly or assist with that process; however, we can provide you with a letter stating the dates services were provided and cost incurred.
We are a very small university-based clinic; therefore, all of our correspondence is primarily conducted through email. Please let us know if you have any questions at [email protected].
We will contact you when your child is next on the waiting list to receive services. In the meantime, if you need referrals to outside providers, we are happy to send you that information via email.
We look forward to working with you and your family!
Warmest regards,
Jennifer N. Fritz, PhD, BCBA-D Director, Severe Behavior Disorders Research Clinic Associate Professor of Behavior Analysis rev 6.22.2016 Initial Caregiver Questionnaire
Date Completed: Please return your answers to this questionnaire via email to [email protected] or you may FAX it to 281-283-3510 with Attention: Dr. Fritz.
Caregiver’s Name: Child’s Name:
Phone Number: Child’s DOB:
Email Address: Child’s Diagnoses:
Child’s Height: Child’s Weight: Child’s Vaccination Status: ____ Fully vaccinated ____ On Track to Full Vaccination ____ Partially vaccinated ____ Unvaccinated Home Address:
Child’s Current Medications (Please list medication, dose, and regimen):
GENERAL QUESTIONS How did you find out about our clinic?
Did you review the information on our website (https://sites.google.com/site/drjnfritz/)? If so, was the information provided helpful to you?
COMMUNICATION How does the child request attention from others? (Please describe what these behaviors look like.)
How does the child request a break from work? (Please describe what these behaviors look like.)
How does the child request access to preferred items and activities? (Please describe what these behaviors look like.)
PREFERRED ITEMS/ACTIVITIES What are the child’s favorite toys and activities? TOYS (examples: dolls, trucks, sensory items – lights, vibration, etc.) ACTIVITIES (examples: arts & crafts, coloring, watching movies, reading, board games): rev 6.22.2016
Does your child engage in problem behavior when preferred items are removed or if the child is not allowed to have something he or she wants?
Is it possible to bring items to the clinic to be used during session?
PROBLEM BEHAVIORS
Please check all problem behaviors that the individual exhibits below. Self-injurious Behavior Aggression Against Others Dangerous Acts Head banging Hitting Eating inedible objects Head hitting Kicking Running away Body hitting Biting Climbing Self-biting Scratching Setting fires Skin picking Pinching Pulling out hair Head butting Other Behaviors Hitting self with object Throwing objects at others (Please describe how it looks) Hair pulling Disruption / Destruction Throwing objects Stereotypy Overturning furniture Hand flapping Breaking items Body rocking Kicking surfaces Hand mouthing Hitting surfaces Mouthing objects Slamming doors Bizarre/repetitive vocalizations Screaming Hair twirling Spitting Noncompliance
What is the behavior for which you would like the most immediate assistance?
How frequently does this behavior occur?
Would the behavior occur with a therapist in a clinic setting without you present? rev 6.22.2016
Does the child exhibit any behaviors that suggest or predict that he/she will probably engage in problem behavior? If so, what do these behaviors look like?
Please describe the most severe episode of problem behavior. What was happening when the behavior occurred? What kind of injury or damage was caused by the behavior?
WORK ACTIVITIES
What types of tasks are difficult for the child or tend to occasion problem behavior? Self-care Early learning skills Other Tasks (Please describe how it looks) Meal time Tolerating specific sounds or loud noises Writing skills Social interaction
Math skills Physical activity
Reading skills Physical assistance with tasks
If specific tasks or materials evoke problem behavior, is it possible to bring those items to the clinic to be used during session?
PROBLEMATIC SITUATIONS
Please check all situation(s) in which problem behavior occurs for which you would like the most help When asked to do something When trying to leave an undesired activity, setting, or person Other Situations When no one is around When specific people are present (Please describe how it looks) When he/she is completing a task When people stop interacting with him/her When access to an item or activity When you tell him/her to stop is denied engaging in the behavior When an item or activity is When you or other are providing removed attention to others in their presence When trying to get access to an Being in a noisy setting item or activity When no one is giving attention to In a specific setting or location him/her When trying to get a reaction When moving from one location/area from others to another When having to wait for preferred When there is a change in daily item or activity routine When having to interact with new When having to interact with new rev 6.22.2016 people items During self-help skills When he/she is in pain or ill During meal time
INTERVENTION STRATEGIES
How do you currently handle problem behavior?
How well does each strategy work?
FINAL COMMENTS Please describe any other issues we should know before the initial consultation below. (Please return your answers to this questionnaire via email to [email protected] or you may FAX it to 281-283-3510 with Attention: Dr. Fritz.)