Behavioral Intervention Plan Form

Name: Date:
School: _____________________________ Grade: _________
This Behavioral Intervention Plan (BIP) is being created in response to exhibited persistent and/or severe
behavior that 1) interferes with the student’s learning or the learning of others and 2) warrants interventions
to positively redirect the targeted behavior. This BIP identifies the type and cause of the behavior, the
replacement behavior, positive interventions and support to reinforce the replacement behavior, and
appropriate consequences. The plan defines how the student will be taught the skills needed for behavior
modification, and provisions for monitoring progress and crisis management.

Problem Behaviors: Frequency: Intensity: Duration:

General Academic Issues:

__work is too hard
__not enough practice
__not enough help
__not generalized skill

General Behavior Issues:

__Lacks ability to perform expected behavior
__needs practice or modeling
__Requires more structure
__Cannot apply across settings

General Communication Issues:

__to request assistance
__to request a break
__to indicate a need
__to indicate frustration

FUNCTIONS of the Behaviors: What purpose does the identified behavior(s) seem to serve for the
child?
Escape ____
_____Avoid a demand or request
_____Avoid an activity
_____Avoid a person
_____Escape the school
_____Other ________

Sensory/Perceptual____
_____Automatic sensory stimulation
_____Perceptual reinforcement
Attention/ Control_____
_____Gain adult attention
_____Gain peer attention
_____Get sent to a preferred adult
_____Other ______________

Gain Desired Item______

_____Get desired item/activity/area
_____List:______________________

Intervention Strategies
1. Environment and/or Circumstances
How can the environment or circumstances that trigger the behavior (or the result of it) be adjusted?

Staff Responsibility:

Student Responsibility:

2. Curriculum and/or Instruction

What changes in the curriculum and/or instructional strategies will be helpful, and who will make it happen?

Staff Responsibility:

Student Responsibility:

3. Other Strategies or Positive Supports (including school personnel, peers, or family)

Staff Responsibility:

Student Responsibility:

Desired Replacement Behavior

What behavior will be taught to replace the targeted behaviors? How will it be taught/re-taught/reinforced, and by who?

Rewards and/or Motivators

How will the student be reinforced so that the replacement behaviors are more motivating than the problem behavior?
Consequences
What consequences will be implemented for repeated occurrences of the problem behavior?

1st Occurrence—

2nd Occurrence—

3rd Occurrence—

Crisis Plan
How will an emergency situation or behavior crisis be handled?

Crisis Team: For behaviors that threaten the safety of the child or of others, the Crisis Team will be called and
procedures implemented as per Policy 4373.

Monitoring of Behaviors (How the behaviors will be assessed and evaluated):

What data will be collected:

How it will be collected:

Who will collect it: Case Manager, ______________________

How will parents be notified of progress:

Date the plan will be reviewed:_________________________

Signature of Parent: _____________________________________ Date: ____________________________

Signature of Staff:

I have reviewed this behavior intervention plan and am knowledgeable of my duties in its
implementation.

Administrator:____________________________________ Date:___________________________

Regular Educator:_________________________________ Date:___________________________

Special Educator: _________________________________ Date:___________________________

Other: __________________________________________ Date:___________________________

Other: __________________________________________ Date:___________________________