Functional Behavior Assessment

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Client's Information

Client's Name	Date of Assessment	Reason for Referral

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Background Information

1. Relevant History

   • Medical/Mental Health Concerns:

   • Developmental Milestones:

2. Sources of Data

• Interviews:

• Direct Observations:

• Records Review:

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Target Behavior(s)

• Specific Behavior(s) of Concern:

  1. Verbal Outbursts:

  2. Leaving Classroom:

  3. Noncompliance:

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Assessment Criteria

Criterion	Description	Rating (High/ Moderate/ Developing)
Frequency of Behavior	Verbal outbursts occur daily; leaving the classroom occurs 2–3 times weekly.
Intensity of Behavior	Verbal disruptions significantly interfere with peers' focus and group activities.
Duration of Behavior	Outbursts and off-task behaviors average 5–10 minutes per incident.
Triggers/Antecedents	Structured activities requiring focus or group participation often precede the behaviors.
Consequences of Behavior	Behaviors typically result in removal from group settings, providing temporary escape.
Setting Factors	Noisy or overstimulating environments appear to exacerbate behaviors.
Replacement Behaviors	Using hand signals to request breaks instead of leaving the classroom or shouting.

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Section 5: Observational Data

Observation Summary

• Date(s): March 8, 10, and 12, 2086

• Location(s): Classroom and cafeteria

• Observation Notes:

  • March 8: Verbal outburst occurred during a group math task after being asked to wait for his turn. Erica Price shouted, "This is stupid!" and left his seat.

  • March 10: During reading time, Erica Price left the classroom without asking and was found wandering the hallway.

  • March 12: During art, Erica Price refused to follow instructions, repeatedly saying, "No, I don’t want to," disrupting peers.

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Recommendations

1. Intervention Strategies:

2. Behavior Intervention Plan (BIP):

3. Ongoing Monitoring:

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Evaluator's Signature

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