Functional Behavior Assessment Parent Interview Form

Student & Site: Person Completing Form:

Relationship to Student: Date:
The information requested in this interview will be used to generate a Positive Behavior Support Plan. It will not be used to evaluate the performance of staff
members or parents. We appreciate your time effort and thought in completing it. All responses will be kept confidential and the final plan will be available only
to parents and staff who interact directly with this student.
1. Please identify & describe behaviors you are concerned about in the table below:
Behavior How often? How long How severe? Where does When does What is Who is with
does the High,Medium, or the behavior the behavior happening your child
behavior last? Low happen? happen? when the when behavior
behavior happens?
occurs?
Screaming
Yelling
Swearing
Hitting,
kicking or
pushing adults
Hitting,
kicking or
pushing other
kids
Biting

Spitting

Throwing

Tipping
Furniture
Sweeping
Surfaces
Sexualized
behaviors
Drops to floor
Self Abuse

Destroys
property
Other:

Other:

2. What may be reinforcing the behavior? (Please choose 3 high frequency problem behaviors and 2 high frequency positive behaviors.)
When problem behavior Parent/Caregiver usually Other kids usually respond Other people usually
listed below occurs: respond by: by: respond by:
1.

2.

3.

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When positive behavior Parent/Caregiver usually Other kids usually respond Other people usually
listed below occurs respond by: by: respond by:
1.

2.

3. Please complete the chart below for sensory issues that appear to affect your child?
Area Sensitivity to: Excessive interest Describe behavior Strategies tried, were they
in: successful?
Vision

Hearing

Touch

Taste

Smell

Sense of body
in space (whole
body response)
4. Communication
Receptive: I estimate my child understands about % of what is said to him/her in his/her native language (
) and about % of what is said in English. Please rate the following strategis that may support your child’s
understanding of spoken communication and how important you think it is for your child:
Communicative Strategy Required Helpful Not Needed
Communication to child is kept short & simple
Limit directions to: One Step
Two Steps
Three Steps
Provide gestures, obvious cues in facial expression
Provide photo/picture drawing prompts
Use sign language
Model desired behavior
Provide physical prompts-support throughout activity
Hand over hand support to learn new routines
Other:

Expressive: How does your child express needs, wants or feelings; respond to directions & answer questions?
Communication behavior Frequently Often Sometimes Seldom Never
Crying, whining, fussing

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Socially inappropriate behavior (what?)
Aggressive behavior (what?)

Pulls adult towards object/area

Brings stuff to adult
Points
Uses communication device
Uses signs
Uses pictures or photographs
Speaks Partially understandable phrases,
with unrelated to context
Partially understandable phrases,
related to context
Understandable, unrelated phrases
Understandable, phrases/sentences
related to context
Other strategy:

5. Please write your thoughts about how difficulty with communication may be impacting your child’s behavior:

6. Identify what you think your child is trying to get, avoid, or tell you with the problem behavior and suggest ways you
would rather see him/her get the same outcome:
When child behaves He/She is or Or Your child could achieve this outcome by: (write 2
this way: (write behavior trying to AVOID: TELL YOU: better ways the child could get, avoid or tell you the same
below) GET: thing in a way you could approve of)
1)

2)

1)

2)

1)

2)

7. What have you seen your child do (at least sometimes) that is a positive first step toward the positive behaviors you
listed above?

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8. Considering your child’s physical and cognitive skills, what could we teach him/her so he/she could meet his/her needs
without using problem behaviors?

9. How have you tried to deal or cope with this behavior in the past? What has been successful, what has been
unsuccessful?
What you tried: What part worked? What didn’t work?

10. What medications is your child taking (if any), do they impact behavior?

11. What physical or medical issues (if any) does your child have that may affect him/her? (e.g., asthma, allergies, rashes,
sinus infections, seizures)

12. Describe your child’s sleeping patterns, & report to what extent they impact his/her behavior?

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13. Describe your child’s eating routines & diet, and the think hunger, food compulsions, food odors or discomfort in the
digestive system may affect his/her behavior.

14. Mark conditions in your child’s life that may be a “set up” for problem behaviors to happen, and list how frequently
they have happened over the past year (estimate):
Setting bad little meds bus change or other other other other
Events night, or or no change issues conflict at
Ongoing poor sleep break- &/or home
issues or fast issue
things that How frequent: How frequent: How
lead to How frequent: How How frequent:
How How
problem frequent: frequent: How frequent: frequent:
behavior frequent:
Trigger getting I am Has to has change or not Has to NOT other
Event directions under- do some- getting
too busy wait issues transi-ions
which standing thing what
occurred to respond with
brothersis what I say he/she he/she
right before How frequent: doesn’t wants How
the How ter
frequent:
want to frequent:
behavior How How frequent: do How
happened frequent: How How
How frequent:
frequent: frequent:
frequent:
15. Based on your family beliefs and cultural values, please describe your expectations for your child’s behavior at this
time:

16. What chores does your child do at home? Does he/she take responsibility for his/her own things?

17. How many people interact with your child at home? How old are they? Do you believe these interactions affect your
child’s mood or behavior? If so, how?

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18. What talents, interests or hobbies does your child have at home?

19. What activities, events, people or things does your child like?

20. Please describe your hopes and dreams for your child’s future after preschool services conclude. Include what
community activities you see your child involved in:

21. Briefly describe a typical school day at home (what does the day look like):

22. Briefly describe a typical weekend or vacation day at home:

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Thank you for the time and effort put into completing this document!

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