<p> Student Functional Assessment Interview</p><p>1. Strengths: What are some things that you like to do? What are you interested in? What are you good at?</p><p>2. Behavior - What are some things you do at school that get you in trouble? </p><p>3. “Hot Buttons” - When you have one of these problems, what usually sets it off? (long assignment, written work, name calling, certain kids being around, boring assignment, working in groups, teacher remark)</p><p>4. “Set ups” - Is there anything that makes it more likely that you’ll have a problem? (certain classes, certain times of the day, after an argument with a boyfriend/girlfriend, fight in the hallway before class, etc.)</p><p>5. Consequences - What usually happens right after you do something that gets you in trouble? (talk to Mr. Dyer/Mr. Patton, teacher yells, sent to Sun Center, kids laugh, detention, etc.)</p><p>6. Why do you keep doing things that get you in trouble? (end up getting out of work, kids think it’s funny, like to get the teacher’s attention, etc.) 7. Your teachers want to help you change your behavior. Can you give them any ideas about things they could do differently in the classroom that would help you behave better?</p><p>8. What are some rewards that you would be willing to work for as you show the teachers you can behave well at school? (See attached paper for ideas, or have the student fill it out)</p><p>------End of Interview------Fill this out based on above information.</p><p>Set-ups Hot Buttons Behavior Consequence 1.</p><p>2.</p><p>Perceived Reason for Behavior (Circle One): Get attention from peers Get attention from adults Get out of doing difficult work Get out of doing boring work Get away from authority Other ______</p><p>Signature ______Date ______Reinforcer Survey</p><p>Name: ______</p><p>Directions: Place a check mark next to all of the types of activities or consequences that you would like to work for. If there is something you would like to work for, but it is not listed, write it in the blank space below.</p><p>_____ Read magazines _____ Work on a puzzle _____ Earn extra minutes of free time _____ Listen to music on headphones _____ Earn time to shoot basketball in the gym _____ Use the computer _____ Design the bulletin board _____ Choose a mystery prize _____ Be the leader of my group _____ Be the classroom monitor _____ Answer the phone for the teacher _____ Pass out materials _____ Get fewer homework problems _____ Earn bonus points _____ Read comic books _____ Work on art project _____ Spend time working in main office _____ Get your favorite snack or drink ______Eat lunch with my favorite teacher ______Extra time with a friend______</p><p>My favorite teachers or staff are: ______</p>