SCHOOL DISTRICT OF LEE COUNTY PARENT/GUARDIAN INTERVIEW FOR FUNCTIONAL BEHAVIOR ASSESSMENT
Child:					Date:
Date of Birth:			Grade/Teacher:
Identify the behavior that find most problematic (i.e. verbally abusive, throws tantrums, aggressive, etc.)
How long have the behaviors been occurring?
Describe what occurs prior to the inappropriate behavior?
When are the behaviors most often observed? (Circle One)
Before School	After school			Dinner Time					Before Bedtime
How would you describe your child’s mood? (Check)
Quiet:		Impulsive:						Defiant:
Withdrawn:		Easily Annoyed:						Agitated:
What type of consequence is given when your child acts out? (Check one/all that apply)
Time Out:		No Play Time:						Other:
No TV/Video:		Sent to Room:
Verbal Reprimand:		Add’t Chores:
Do you feel your methods are effective? (Circle One)						Yes				No
How does your child respond to consequences?
Describe your child’s best behavior or perfect day.
When are your child’s appropriate behaviors most often observed? (Circle One)
Before School	After School			Dinner Time					Before Bedtime
What type of reward do you give your child when he/she has demonstrated appropriate behavior? (Check one/all that apply)
Treat:				Extra TV Show:
Stickers:				Chore Elimination:
Extra Play Time:				Positive Feedback:
Outside Time:				Video Games:
Do you find that your child responds more favorably to tangible rewards (i.e. stickers, snacks) or tangible rewards (i.e. smile, verbal praise)? (Check One)
Tangible:				Intangible:
How consistent is positive behavior? (Check One)
Hourly:		Daily:						Weekly:
Is there a particular setting that seems most conducive to promoting good behavior?
One-on-One:				Family Gatherings:
Group Setting:				Peer Interactions:
How long does the negative behavior continue? (Check One)
5-15 minute intervals:				15-30 minute intervals:
30-45 minute intervals:				45-60 minute intervals:
Daily:				Weekly:
Is your child able to discuss his/her feelings with you or another family member?
Yes:				No:
What type of activity does your child enjoy most? (Check all that apply)
Drawing:		Play:					TV/Video Games:
Reading:		Other:					Outside Activities:
Does your child prefer to be by himself/herself or does he/she readily engage with others?
Please identify any other characteristics about your child that you feel would be beneficial: (i.e. medication, medical history, childhood illnesses, substance abuse issues, history of mental illness in family, physical/emotional abuse, etc.)