Restraint/Seclusion Debriefing Form
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Student Name
Date of Debriefing
Time of Debriefing
Individuals in Attendance (Check all that apply)
Give a brief description of the circumstances leading up to this point:
Give a summary of incident:
What was the intervention used?
What was the outcome?
From the information gained at the meeting what needs to be changed?
Has a support plan/contract been initiated?
Clear selection
Is this is a repeated instance of restraint or seclusion, if so, an FBA shall be conducted.  Has an FBA been initiated?
Clear selection
Additional Comments
Clear form
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