<p> Functional Behavioral Assessment</p><p>Name (First, MI, Last): Record #: DOB: Organization/Program Name: Date of Assessment: Data Source: Observation Person Served Interview Parent Interview Teacher Interview Rating Scales Normative Testing Other Definition of Target Behavior (#: ) Define in measurable and observable terms</p><p>Setting(s) in which behavior occurs: </p><p>Frequency: </p><p>Intensity (consequences of problem behavior on person served, family, peers, education): </p><p>Duration: </p><p>Describe previous interventions: </p><p>Impact (on person served, family, community, peers, others): </p><p>Function of Problem Behavior (Conditions that impact the frequency and the consequences that help maintain the likelihood of occurrence): Setting Events- These are general conditions or events that increase the likelihood that a triggering antecedent will lead to a problem behavior: Affective Regulation/Emotional Reactivity (Identify emotional factors, anxiety, depression, anger, poor self-concept, that play a role in organizing or directing problem behavior): </p><p>Cognitive Distortion (Identify distorted thoughts; inaccurate attributions, negative self-statements, erroneous interpretations of events, that play a role in organizing or directing problem behavior): </p><p>Family Issues (Identify family issues that play a part in organizing or directing problem behavior): </p><p>Modeling (Identify the degree to which the behavior is copied, who the person served is copying the behavior from, and why he/she is copying the behavior): </p><p>Physiological/Constitutional (Identify physiological and/or personality characteristics; developmental disabilities, temperament; that play a part in organizing and directing problem behavior): </p><p>Other Environmental Conditions: (Identify what role the school, community, peers, others play in organizing and directing problem behavior):</p><p>Triggering Antecedents- These are specific events that immediately trigger or precipitate this behavior. Reprimand/Correction Demands Unstructured Time Social Demands </p><p>Page 1 of 6 Review Date: 4-30-13 Functional Behavioral Assessment</p><p>Name (First, MI, Last): Record #: Time with Peers/Siblings/Other Family Members Being Denied Something </p><p>Maintaining Consequences- These are the consequences of the behavior that are likely to function to maintain this behavior. Conditions that are obtained: Adult Attention Peer Attention Preferred Activity Communication Need (Identify what the person served is trying to say through the problem behavior): </p><p>Money/Things Other </p><p>Conditions that are Avoided or Escaped From Tasks Reprimands Peer Negatives Adult Attention Physical Effort Other </p><p>Definition of Target Behavior (#: ) (Define in measurable and observable terms)</p><p>Setting(s) in which behavior occurs: </p><p>Frequency: </p><p>Intensity (consequences of problem behavior on person served, family, peers, education): </p><p>Duration: </p><p>Describe previous interventions: </p><p>Impact (on person served, family, community, peers, others): </p><p>Page 2 of 6 Review Date: 4-30-13 Functional Behavioral Assessment</p><p>Name (First, MI, Last): Record #: Function of Problem Behavior (Conditions that impact the frequency and the consequences that help maintain the likelihood of occurrence.) Setting Events- These are general conditions or events that increase the likelihood that a triggering antecedent will lead to a problem behavior: Affective Regulation/Emotional Reactivity (Identify emotional factors, anxiety, depression, anger, poor self-concept, that play a role in organizing or directing problem behavior): </p><p>Cognitive Distortion (Identify distorted thoughts; inaccurate attributions, negative self-statements, erroneous interpretations of events, that play a role in organizing or directing problem behavior): </p><p>Family Issues (Identify family issues that play a part in organizing or directing problem behavior): </p><p>Modeling (Identify the degree to which the behavior is copied, who the person served is copying the behavior from, and why he/she is copying the behavior): </p><p>Physiological/Constitutional (Identify physiological and/or personality characteristics; developmental disabilities, temperament; that play a part in organizing and directing problem behavior): </p><p>Other Environmental Conditions: (Identify what role the,school, community, peers, others play in organizing and directing problem behavior):</p><p>Triggering Antecedents- These are specific events that immediately trigger or precipitate this behavior. Reprimand/Correction – we should define each of these for the manual for each item below: Demands Unstructured Time Social Demands Time with Peers Being Denied Something</p><p>Maintaining Consequences- These are the consequences of the behavior that are likely to function to maintain this behavior. Conditions that are obtained: Adult Attention Peer Attention Preferred Activity Communication Need (Identify what the person served is trying to say through the problem behavior): </p><p>Money/Things Other </p><p>Conditions that are Avoided or Escaped From Tasks Reprimands Peer Negatives Adult Attention Physical Effort Other </p><p>Page 3 of 6 Review Date: 4-30-13 Functional Behavioral Assessment</p><p>Name (First, MI, Last): Record #: Definition of Target Behavior (#: )(Define in measurable and observable terms)</p><p>Setting(s) in which behavior occurs: </p><p>Frequency: </p><p>Intensity (consequences of problem behavior on person served, family, peers, education): </p><p>Duration: </p><p>Describe previous interventions: </p><p>Impact (on person served, family, community, peers, others): </p><p>Function of Problem Behavior (Conditions that impact the frequency and the consequences that help maintain the likelihood of occurrence. : Setting Events- These are general conditions or events that increase the likelihood that a triggering antecedent will lead to a problem behavior: Affective Regulation/Emotional Reactivity (Identify emotional factors, anxiety, depression, anger, poor self-concept, that play a role in organizing or directing problem behavior): </p><p>Cognitive Distortion (Identify distorted thoughts; inaccurate attributions, negative self-statements, erroneous interpretations of events, that play a role in organizing or directing problem behavior): </p><p>Family Issues (Identify family issues that play a part in organizing or directing problem behavior): </p><p>Modeling (Identify the degree to which the behavior is copied, who the person served is copying the behavior from, and why he/she is copying the behavior): </p><p>Physiological/Constitutional (Identify physiological and/or personality characteristics; developmental disabilities, temperament; that play a part in organizing and directing problem behavior): </p><p>Other Environmental Conditions: (Identify what role the,school, community, peers, others play in organizing and directing problem behavior):</p><p>Triggering Antecedents- These are specific events that immediately trigger or precipitate this behavior. Reprimand/Correction – we should define each of these for the manual for each item below: Demands Unstructured Time Social Demands Time with Peers Being Denied Something </p><p>Maintaining Consequences- These are the consequences of the behavior that are likely to function to maintain this behavior. Conditions that are obtained: Adult Attention Peer Attention </p><p>Page 4 of 6 Review Date: 4-30-13 Functional Behavioral Assessment</p><p>Name (First, MI, Last): Record #: Preferred Activity Communication Need (Identify what the person served is trying to say through the problem behavior): Money/Things Other </p><p>Conditions that are Avoided or Escaped From Tasks Reprimands Peer Negatives Adult Attention Physical Effort Other </p><p>Clinical Formulation – Interpretive Summary (Based on the FBA sections above and any supporting documentation such as a behavior support plan worksheet) This Clinical Formulation is Based Upon Information Provided By (Check all that apply): Person Served Parent(s) Guardian(s) Family/Friend(s) Physician Records Law Enforcement Service Provider School Personnel Other: Interpretive Summary: What in your clinical judgment are the functional need areas, the factors that led to the needs, and your plan to address them? </p><p>Prioritized Target Behaviors: A-Active, PD-Person Declined, D-Deferred, R-Referred Out A PD* D* R* (If declined/deferred/referred out, please provide rationale) 1. </p><p>2. </p><p>3. </p><p>4. </p><p>5. </p><p>6. </p><p>Page 5 of 6 Review Date: 4-30-13 Functional Behavioral Assessment</p><p>Name (First, MI, Last): Record #: Provider - Print Name/Credential: Supervisor - Print Name/Credential (if needed):</p><p>Provider Signature: Date: Supervisor Signature (if needed): Date:</p><p>Person’s Signature (Optional) Date: Parent/Guardian Signature (Recommended): </p><p>MD Signature (if needed): Date: Next Appointment if applicable: Date: / / - Time: am pm Date of Provider Loc. Mod Start Stop Total Diagnostic Prcdr. Code Mod2 Mod3 Mod4 Service Number Code 1 Time Time Time Code</p><p>Page 6 of 6 Review Date: 4-30-13 </p>