Parent Interview Questions-FBA

My name is Brittany Kocher and I am the Behavior Specialist for Brooke County Schools. I am completing a Functional Behavior Assessment (FBA) on your child.  I need some information from home to finish the assessment. Please fill out all questions and submit it. I appreciate you taking the time to fill out the form.  If you have any questions, please feel free to email me bkocher@k12.wv.us or call me at 304-527-1410 ext. 3572.

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Email *
Child's Name *
Age *
Grade *
School
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Informant's Name *
Relationship to Child *
What concerns do you have regarding your child’s behavior? *
2. Which of these concerns/behaviors are most important to you at this time?  What about those behaviors makes them the most problematic? *
3. Does the behavior occur when your child is with you?When does the behavior occur? *
4. When doesn’t the behavior occur? When does it occur the least? When does it occur the most? *
5. Are you aware of anything that appears to cause your child to start the behavior?  What things seem to set him or her off? *
6. What do you typically do when your child exhibits the behavior? *
7. What do your child’s peers typically do when your child exhibits the problem behavior?
8. When did the problem first appear? *
9. Did anything change in your child’s life at about that time? *
10. What have you been doing to attempt to change your child’s behavior? *
11. Did you perceive an improvement, a deterioration, or no change following the implementation of your management plan? *
12. Does your child have any sensory problems of which you are aware? *
13. Does your child have any health problems that may be contributing to the behavioral problem? *
14. Are there other factors related to your child’s behavior of which you think I should be aware? *
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