Fillable Request For Behavior Services Consultation Form printable pdf download

The School Board of St. Lucie County

Request for Behavior Services Consultation

Student Name: _________________________________ Student ID#________________________

School: ___________________________ DOB: _________________ Grade:_________________

Exceptionality (if applicable): _______________Teacher: ______________________________________

Does the behavior involve aggression toward others, property destruction, self-injury, or self-stimulation?

Yes: ________ No: __________ (If yes, please circle behaviors above)

Please describe the behaviors specifically: ___________________________________________________

_____________________________________________________________________________________

Has a functional behavior assessment and behavior intervention plan (FBA/BIP) been done in the past?

Yes________ No_________

If yes, please attach the plan and any available data.

Please describe previous attempts to resolve this problem: _______________________________________

_____________________________________________________________________________________

Is this FBA/BIP being done by the _____Student Support Team or by the _____IEP team? (Check one)

Who at your school will coordinate this FBA/BIP?

Name: _____________________________ Position: _________________________________________

Please list other team members who will participate: __________________________________________

____________________________________________________________________________________

Note to Coordinators: The Student Support Team Initiation Form/Functional Behavior Assessment Short

Form (form XED 0083 pp. 1-5), is the form that should be used for completing most FBA/BIPs. If you have

questions or need assistance regarding the short form or additional forms that may be used, please contact

behavior services.

Prior to meeting with the behavior analyst, please check off that the following parts of the FBA/BIP

have been completed.

_____________ parental permission for observation (either permission for screening, form STS0076, or

consent for re-evaluation, form XED 0041)

_____________identification and definition of the problem behavior so that the teacher may collect about

two weeks of scatterplot data (form XED 0083, p. 5). (Please consult with behavior services if you need

help clearly defining the problem behavior prior to data collection.)

_____________ identification of team members and possible meeting times

Please check services requested:

__________ direct observation of the student and consultation with your team as you write the

hypothesis statements and behavior intervention plan.

__________ on-site support to the teacher, if desired, to model and give suggestions to help with the

implementation of the behavior intervention plan.

__________ attendance at future team meetings to help analyze the data and assist with decision

making.

__________suggestions for class-wide intervention strategies that are not related to a single student ( fill

in applicable information only if requesting this option alone)

Are there any precautions, medical concerns, or other circumstances that the behavior analyst should be

aware of prior to the observation? _________________________________________________________

_____________________________________________________________________________________

Referred by: _____________________________________________ Date:_______________________

Signature

Building Administrator: ___________________________________ Date:_______________________

Signature

Please fax or send this referral to attention of the secretary for Behavior Services at ESE office. Thank you.

For office use only: Date Received: ___________________Assigned to:______________________________ Date:______________

Date logged into database: ____________________

XED 0184 10/02

Request For Behavior Services Consultation Form

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