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Functional Behavioral Assessment Form

A Functional Behavioral Assessment Form Template is a complex form designed to collect details about a student’s problematic behaviors, skills, and even medical history.

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Functional Behavioral Assessment Form Template

Use Functional Behavioral Assessment Form Template to properly assess a student

Functional Behavioral Assessment Form

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Functional Behavioral Assessment Form (#18)

First Name

Last Name

Date

Sources of Data

Record Review

Scatterplot

ABC Logs

Other

Describe the data source

Information Reported by:

Teacher

Parent

Student

Other

Describe your role.

Assessor Name(First Name)

Assessor Name(Last Name)

Problem Behaviors

Describe behaviors in specific and observable terms.

Estimated frequency

Describe any observed patterns related to reported behavior.

Medical/Health Information

Known health, medical, or psychiatric conditions

Current medications

Effects and side-effect of medication

Known traumatic events

Medical treatments, therapies, or services (outside of school)

Intervention History

Describe a brief history of the problem behavior and any interventions.

If applicable, how would you describe the effectiveness of past intervention efforts?

What rewards are currently provided to the student in school? For what and how often?

What consequences are currently used in school for problem behaviors?

What is the typical student response to these consequences?

Skills Assessment

What are the student's academic strengths?

What are the student's academic needs?

What are the student's organizational needs?

What are the student's preferred learning styles?

What are the student's social strengths?

What are the student's deficits in regard to social skills with adults and peers?

Communication Summary

Does the student have difficulty in expressing any of these basic communication functions?

Gaining adult attention

Gaining attention of peers

Dealing with a difficult task

Expressing frustration or confusion

Requesting things of others

Rejecting or protesting something

Indicating preferences or making choices

Requesting assistance

Use the summary below to think about and identify possible replacement behaviors for instruction. Number separate issues in each of the the following fields to clearly connect problem behavior to communication function and replacement behavior. Target Problem Behavior(s)

Related Communication Function(s)

Possible Replacement Behavior(s)

Consequence Analysis

Thinking about the last few times the behavior occurred, what typically actually happens immediately afterward?

Are demands typically altered after the target behavior?

Does someone usually intervene to help the student after the target behavior?

Does the student gain access to something that he/she appears to want?

Does the behavior appear pleasurable to the student apart from what else is going on around him/her?

Does the behavior appear to give the student control of others or the situation? Explain.

Does the behavior, or do related behaviors, appear to be compulsive (i.e., repetitive, internally driven)? Explain.

About this template...

A Functional Behavioral Assessment Form Template is a complex form designed to collect details about a student’s problematic behaviors, skills, and even medical history.

Functional Behavioral Assessment Form

Features of this Template

Multi-step
Medical history
Skill assessment
Thorough analysis of problematic behavior

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Features of this Template

Multi-step
Medical history
Skill assessment
Thorough analysis of problematic behavior

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