Behavioral Intervention Plan MCPS Form 336-65

Office of Student and Family Support and Engagement August 2016

MONTGOMERY COUNTY PUBLIC SCHOOLS Page 1 of 3
Rockville, Maryland 20850

STUDENT INFORMATION:

Name _____________________________________________________ MCPS ID Number____________________ Date _____/_____/______

Date of Birth _____/_____/______ Grade _____ School _________________________________________________________________

General Education □ Section 504 □ Special Education □ (disability): ______________________________________________

TEAM INFORMATION: This form should be completed by a team that, at a minimum, includes one of the student’s classroom
teachers, the school counselor, and school psychologist/social worker.

Teachers: School Counselor:

Psychologist:
Social Worker:
Other Team Members:

REPLACEMENT BEHAVIOR: Describe hypothesized function(s) of each problem behavior

Describe replacement behavior that addresses the student’s need(s) (use measurable, observable, and specific terms)

Identify strategies to prevent problem behavior (e.g., address setting events and antecedents)

Identify strategies to teach/increase replacement behavior (e.g., modeling, teaching, and reinforcing desired behavior)
 MCPS Form 336-65
Page 2 of 3
Identify strategies to respond if/when problem behavior occurs. Consider the function of the behavior. Avoid unintentionally
reinforcing the problem behavior. Address crisis response if necessary.

Identify setting(s) for implementation of intervention(s)

INTERVENTION PLAN AND SCHEDULE: This section will describe the plan and time table to evaluate the effectiveness of the
intervention plan.
Specify current, measurable level(s) of performance (i.e., baseline)

Specify goal

What will be measured and how will it be measured?

When will data be collected?

Where will data be collected?

Who is responsible for data collection?

Specify plan for crisis/emergency intervention, if necessary

Determine schedule (include dates) to review/modify the intervention plan as needed

ATTACH Behavioral Intervention Plan Review Sheet and supporting data at each review date. There should be at least three
instances of data collection to determine effectiveness of intervention.
 MCPS Form 336-65
Page 3 of 3

Behavioral Intervention Plan Review Sheet

STUDENT INFORMATION:

Name _____________________________________________________ MCPS ID Number____________________ Date _____/_____/______

RECORD OF REVIEW AND REVISION

Review of progress from _____/_____/______ to _____/_____/______ (insert dates)

Goal for this review period ______________________________________________________________________________________________

Current level of performance (attach data sheets)

CONCLUSIONS:

□ Assessment and plan successful; continue with strategies, no changes need.

□ Assessment and plan successful; modify as indicated below.
□ Assessment and plan unsuccessful; additional assessment needed as indicated below.
□ Assessment and plan unsuccessful; revision of behavior plan needed as indicated below.

MODIFICATIONS TO PLAN: The team may indicate changes in this section or make revisions using only those pages requiring
changes.