аЯрЁБс>ўџ ўџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџ§џџџўџџџўџџџўџџџўџџџџџџџџџџџџџџџџџџџ џџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџRoot EntryџџџџџџџџТлЭ(т ЮЂšЊJrрсf—УРMatOSTџџџџџџџџ К]—Урсf—УMMџџџџџџџџџџџџMN0џџџџ )ўџџџўџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџNDўџ џџџџТлЭ(т ЮЂšЊJrMicrosoft Works MSWorksWPDocє9ВqFunctional Behavior Assessment Sevier County Schools PARENT INTERVIEW Child’s Name _________________________________ Date of Birth ______________ Parent/Guardian’s NamЎ  мё()*+&і аё,-./Times New RomanMT Extra NewZurica BDьi8ар=а/а ьi8ар=а/а dCompObjџџџџџџџџџџџџUџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџ____________________________________________________________________ ______________________________________________________________________________ 8. Does your child express feelings easily? A Yes A No With any specific person? A Yes A No Please describe:__________________________________________________________________ ______________________________________________________________________________ GENERAL BACKGROUND INFORMATION: 1. Is your child currently on medication? A Yes A No If yes, Name _________________________ Dosage ____________ Frequency__________ 2. Has he/she had any chronic health problems?(e.g. asthma, diabetes, heart condition) If yes, specify. ______________________________________________________________________________ 3. Is there any suspicion of alcohol or drug use? AYes A No If yes, specify ______________________ 4. Is there any history of physical/sexual abuse? AYes ANo A Don’t know 5. Does the child have any problems sleeping? A None A Difficulty falling asleep A Sleep continuity disturbance A Early morning awakening 6. Has the child ever had any of the following forms of psychological treatment? (Check those that apply.) ___Individual psychotherapy Duration of therapy ___________________________ ___Group psychotherapy Duration of therapy ___________________________ ___Family therapy with child Duration of therapy ___________________________ ___Inpatient evaluation/treatment Duration ___________________________ ___Residential Treatment Duration ___________________________ 7. Has your child ever been involved with juvenile court? AYes ANo 8. Has your child ever been in any type of special educational program? AYes A No ----------------------------------------------ў•SDD АT›аBё)8888)ьi8ар=а/а d8џџџџаяtЕ8aTFunctional Behavior Assessment Sevier County Schools PARENT INTERVIEW Child’s Name _________________________________ Date of Birth ______________ Parent/Guardian’s Name ________________________________ Date ______________ Interviewer _______________________ Interview Conducted: AAt School ABy phone Please explain each of your answers. 1. What does your child like to do in his/her free time? ______________________________________________________________________________ ______________________________________________________________________________ 2. What does he/she dislike to do in free time? ______________________________________________________________________________ ______________________________________________________________________________ 3. With whom does he/she like to spend time? ______________________________________________________________________________ ______________________________________________________________________________ 4. Does your child go to school willingly? ______________________________________________________________________________ ______________________________________________________________________________ 5. What specific behavior problems at school do you know about? ______________________________________________________________________________ ______________________________________________________________________________ 6. What specific behavior problems occur outside of school? ______________________________________________________________________________ ______________________________________________________________________________ 7. In general, does your child seem happy? ______________________________________________________________________________ ______________________________________________________________________________ 8. Does your child express feelings easily? A Yes A No With any specific person? A Yes A No Please describe:__________________________________________________________________ ______________________________________________________________________________ GENERAL BACKGROUND INFORMATION: 1. Is your child currently on medication? A Yes A No If yes, Name _________________________ Dosage ____________ Frequency__________ 2. Has he/she had any chronic health problems?(e.g. asthma, diabetes, heart condition) If yes, specify. ______________________________________________________________________________ 3. Is there any suspicion of alcohol or drug use? AYes A No If yes, specify ______________________ 4. Is there any history of physical/sexual abuse? AYes ANo A Don’t know 5. Does the child have any problems sleeping? A None A Difficulty falling asleep A Sleep continuity disturbance A Early morning awakening 6. Has the child ever had any of the following forms of psychological treatment? (Check those that apply.) ___Individual psychotherapy Duration of therapy ___________________________ ___Group psychotherapy Duration of therapy ___________________________ ___Family therapy with child Duration of therapy ___________________________ ___Inpatient evaluation/treatment Duration ___________________________ ___Residential Treatment Duration ___________________________ 7. Has your child ever been involved with juvenile court? AYes ANo 8. Has your child ever been in any type of special educational program? AYes A No ----------------------------------------------------------------------------------------------------------------------------------------------------------- To be used additionally if a crisis situation occurs. ANALYSIS OF SPECIFIC BEHAVIOR: Define Behavior(s) _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 1. Possible Causes of Behavior: (Use information collected above....e.g. breakup with girlfriend, fights with parents.) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2. Reactions to Behavior (What has happened when behavior(s) exhibited? What did you as parent do when behavior was exhibited?) ____________________________________________________________________ ____________________________________________________________________ Comments: hool do you knoDVX67DEQt…‡ŠŒЋ­АВЌ Ў {uo{k{k{g{k{k{k{k{k  Ў Б З     v w  € ‡ ˆ Я а л м ћ ќ   {w{w{w{w{w{w{w{w{w{w{ Љ $efmntОПЦЧЪwnЙНиLмysokokokokososososoмочщёyuyuBDVXЋќOQwВT†з(WЈљ&qqkeeeeeeeeeeeeeeee рР!&wШYЊ7ˆЕW \ ^  Ц   а ? • Х : Ј і yyyyyyyyyyyyyyyyyyyyyyyі @  м $&(rtЬЮавoqsuwЎАаyyyyyyyyyyyyyyyyyoiy  @авц?˜ёJLШjЛНL“кмощыэяёyyyyyyyyyyyyyyyyyyyyy