Surveypoint

Q1

Client Name

First Name

Q2

Client Name

Last Name

Q3

Date of Birth

Date

Q4

Sex

Q5

Date Completed

Date

Q6

Living Arrangement: Please describe your home and community:

Q7

Programs/Services: Please list the educational or therapeutic programs( eg., school, day care, OT, PT, seech) in which your child currently participating. Provide contact person and frequency.

Q8

Broad Goals:

Q9

Medical Issues: Describe prenatal and perinatal events, along with a complete developmental history (physical, psychological, social, intellectual, and academic)

Q10

Please list any medical, psychological, psychiatric diagnoses that your child has received including any previous or current infectious diseases.

Q11

Please list any medications your child is taking that could impact his/her behavior: Medication, Dose, Frequency, Reason, Impact/Side effects

Q12

Please describe any additional medical complications (e.g, asthma, allergies, skin conditions, stomach problems, seizures, substance abuse) that could be affecting your child's behavior.

Q13

Does he or she have a primary care physician?

Q14

Primary Care Physician Information (Name, Specialty)

Q15

About how many hours of sleep does your child get each day (including naps)?

Q16

Does he or she sleep through the night?

Q17

Doe your child have any eating habits or dietary restrictions that could affect this or her behavior? If so, please describe.

Q18

Is your child currently experiencing homicidal or suicidal ideations? (If yes, then 1-refer for immediate evaluation by an appropriate psychiatric professional, or 2- call 911, depending on the level of risk).

Q19

Has your child been a victim of abuse of any kind? Has your child been a perpetrator of abuse of any kind? If yes for either of the above, please describe.

Q20

(For teens, 12 and older) If an appropriate, please explain any sexual history behavior:

Q21

Are you aware of any past or current substance abuse your teen may have engaged in including the use of nicotine and alcohol? Please describe

Q22

Has any substance abuse screening occurred? No or Yes

Q23

Pertinent Family History: Please describe any relevant medical family history (e.g., sibling/caregiver's psychological diagnosis, medical conditions, medications/treatments, substance abuse, etc.) that could affect your child's behavior, treatment implementation, and/or the participation of team members.

Q24

Please describe any relevant behavioral family history (e.g, sibling/caregiver's behavioral diagnoses, criminal history, behavioral history, treatments, etc.) that could affect your child's behavior, treatment implementation, and/or the participation of team members.

Q25

Please describe any relevant spiritual variables (e.g., family beliefs, perspectives, rituals, observations, traditions, etc.) that could affect your child's behavior, treatment implementation and/or the participation of team members.

Q26

Describe any legal or marital issues that may impact the implementation of services (e.g., divorce, guardianship, custody issues, etc.)

Q27

Are currently receiving behavioral health services from another provider? No or Yes

Q28

Have you ever received behavioral health services (ABA) in the past? No or Yes? If yes, what was the approximate ranges of dates you saw that provider for? Who was the provider? What were your child's responses to the treatment provided (e.g., what worked, and what didn't work?

Q29

Child's Strengths: What are your child's greatest strengths (e.g., skills, interests)?

Q30

Communication Skills: How does your child communicate his or her needs (please check all that apply? Words, gestures or other form of communication used:

Q31

Request Attention

Q32

Ask for assistance

Q33

Request toy/object

Q34

Initiate activity

Q35

Avoid a situation

Q36

Take a break/stop

Q37

Say "no" to request

Q38

Indicate comfort

Q39

Other skills: Describe your child's ability to perform the following types of skills. Self-care (e.g., dressing, toileting), Daily living (e.g., household chores), Play/leisure (e.g., using toys, games), Academics (e.g., writing, cutting).

Q40

Receptive Communication: Give examples of the ways in which your child responds. Requests or instructions followed. Behavior imitated.

Q41

Potential Reinforcers: What does your child like (e.g., if presented with a variety of options or given free time, what would your child choose)?

Q42

Attention

Q43

Tangibles

Q44

Sensations

Q45

Behaviors of Concern: What does your child say or do that concerns you most (e.g., aggression toward self or others, property destruction, tantrums, screaming, inappropriate interactions, resistance, off-task behavior, substance abuse, sexual behavior)? Estimate how often, how long, how severe.

Q46

1. Behavior

Behavior

Q47

1. Behavior

Description

Q48

Frequency

Q49

Severity

Q50

Duration: (seconds, minutes, hours)

Q51

2. Behavior

Behavior

Q52

2. Behavior

Description

Q53

3. Behavior

Behavior

Q54

3. Behavior

Description

Q55

4. Behavior

Behavior

Q56

4. Behavior

Description

Q57

5. Behavior

Behavior

Q58

5. Behavior

Description

Q59

Which, if any of these occur together?

Q60

In what environments do these behaviors occur?

Q61

Impact of Behavior: How are your child's behaviors affecting your child's development, or participation in activities or settings? What is the impact on your family?

Q62

Interventions Attempted, Whom, When, Impact on Behavior:

Q63

Extracurricular activities: Please describe any extra-curricular activities or community resources that your child is involved with:

Q64

Most Successful

Q65

Most Problematic

Q66

Is your child's daily schedule consistent (i.e Do meals, bedtimes, and other daily events occur at the same time and in the same order)?

Q67

Do you feel that your child generally knows what is going to happen (e.g, where the child will be going, when, and with whom?

Q68

Opportunities for choice: Please describe the different types of choices you child has the opportunity to make on a regular basis (e.g., what to wear, with whom to play, what activities to do):

Q69

Social Influence: With whom is your child's behavior of concern...

Most Likely

Q70

Social Influence: With whom is your child's behavior of concern...

Least Likely

Q71

Possible Triggers: What impact would you expect the following situations to have on your child's behaviors of concern?

Q72

Other situations that are particularly difficult:

Q73

1. Behavior

Q74

2. Behavior

Q75

3. Behavior

Q76

4. Behavior

Q77

5. Behavior

Q78

Behavior Assessment -Form Fill

Client Name

Client Name

Date of Birth

Sex

Date Completed

Living Arrangement: Please describe your home and community:

Programs/Services: Please list the educational or therapeutic programs( eg., school, day care, OT, PT, seech) in which your child currently participating. Provide contact person and frequency.

Broad Goals:

Medical Issues: Describe prenatal and perinatal events, along with a complete developmental history (physical, psychological, social, intellectual, and academic)

Please list any medical, psychological, psychiatric diagnoses that your child has received including any previous or current infectious diseases.

Please list any medications your child is taking that could impact his/her behavior: Medication, Dose, Frequency, Reason, Impact/Side effects

Please describe any additional medical complications (e.g, asthma, allergies, skin conditions, stomach problems, seizures, substance abuse) that could be affecting your child's behavior.

Does he or she have a primary care physician?

Primary Care Physician Information (Name, Specialty)

About how many hours of sleep does your child get each day (including naps)?

Does he or she sleep through the night?

Doe your child have any eating habits or dietary restrictions that could affect this or her behavior? If so, please describe.

Is your child currently experiencing homicidal or suicidal ideations? (If yes, then 1-refer for immediate evaluation by an appropriate psychiatric professional, or 2- call 911, depending on the level of risk).

Has your child been a victim of abuse of any kind? Has your child been a perpetrator of abuse of any kind? If yes for either of the above, please describe.

(For teens, 12 and older) If an appropriate, please explain any sexual history behavior:

Are you aware of any past or current substance abuse your teen may have engaged in including the use of nicotine and alcohol? Please describe

Has any substance abuse screening occurred? No or Yes

Please describe any relevant behavioral family history (e.g, sibling/caregiver's behavioral diagnoses, criminal history, behavioral history, treatments, etc.) that could affect your child's behavior, treatment implementation, and/or the participation of team members.

Please describe any relevant spiritual variables (e.g., family beliefs, perspectives, rituals, observations, traditions, etc.) that could affect your child's behavior, treatment implementation and/or the participation of team members.

Describe any legal or marital issues that may impact the implementation of services (e.g., divorce, guardianship, custody issues, etc.)

Are currently receiving behavioral health services from another provider? No or Yes

Have you ever received behavioral health services (ABA) in the past? No or Yes? If yes, what was the approximate ranges of dates you saw that provider for? Who was the provider? What were your child's responses to the treatment provided (e.g., what worked, and what didn't work?

Child's Strengths: What are your child's greatest strengths (e.g., skills, interests)?

Communication Skills: How does your child communicate his or her needs (please check all that apply? Words, gestures or other form of communication used:

Request Attention

Ask for assistance

Request toy/object

Initiate activity

Avoid a situation

Take a break/stop

Say "no" to request

Indicate comfort

Other skills: Describe your child's ability to perform the following types of skills. Self-care (e.g., dressing, toileting), Daily living (e.g., household chores), Play/leisure (e.g., using toys, games), Academics (e.g., writing, cutting).

Receptive Communication: Give examples of the ways in which your child responds. Requests or instructions followed. Behavior imitated.

Potential Reinforcers: What does your child like (e.g., if presented with a variety of options or given free time, what would your child choose)?

Attention

Tangibles

Sensations

Behaviors of Concern: What does your child say or do that concerns you most (e.g., aggression toward self or others, property destruction, tantrums, screaming, inappropriate interactions, resistance, off-task behavior, substance abuse, sexual behavior)? Estimate how often, how long, how severe.

1. Behavior

1. Behavior

Frequency

Severity

Duration: (seconds, minutes, hours)

2. Behavior

2. Behavior

3. Behavior

3. Behavior

4. Behavior

4. Behavior

5. Behavior

5. Behavior

Which, if any of these occur together?

In what environments do these behaviors occur?

Impact of Behavior: How are your child's behaviors affecting your child's development, or participation in activities or settings? What is the impact on your family?

Interventions Attempted, Whom, When, Impact on Behavior:

Extracurricular activities: Please describe any extra-curricular activities or community resources that your child is involved with:

Most Successful

Most Problematic

Is your child's daily schedule consistent (i.e Do meals, bedtimes, and other daily events occur at the same time and in the same order)?

Do you feel that your child generally knows what is going to happen (e.g, where the child will be going, when, and with whom?

Opportunities for choice: Please describe the different types of choices you child has the opportunity to make on a regular basis (e.g., what to wear, with whom to play, what activities to do):

Social Influence: With whom is your child's behavior of concern...

Social Influence: With whom is your child's behavior of concern...

Possible Triggers: What impact would you expect the following situations to have on your child's behaviors of concern?

Other situations that are particularly difficult:

1. Behavior

2. Behavior

3. Behavior

4. Behavior

5. Behavior

Other Issues: Please feel free to describe other issues you feel could be influencing your child's behavior.