Internal Behavior Report
Client Name
First Name
Last Name
Staff Name
First Name
Last Name
Date of Incident/Behavior
-
Month
-
Day
Year
Date
Time of Incident/Behavior
Location of Incident/Behavior
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Supervisor
First Name
Last Name
Select all behaviors that apply to incident and provide a detailed narrative/explanation of each behavior and the incident.
Physical Behavior
Biting
Choking
Hair Pulling
Head Butting
Hitting/Slapping
Punching
Pushing/pulling
Scratching
Cutting
Other (explain below)
Change in Affect
Feelings of Sadness
Crying
Depressed
Angry
Confused
Anxious
Other (explain below)
Verbal Behavior
Profanity/Cursing
Screaming
False Allegations/Lying
Name Calling
Suicidal Ideation
Other (explain below)
Elopement (choose type or elopement AND severity; two options should be selected)
Eloped from Home
Eloped from Home Assignment
Eloped in Public
Other elopement (please explain)
Severity: Disruptive
Severity: Dangerous
Severity: Very Dangerous
Severity: Crisis
Other (explain below)
Other Behavior
Non-compliance
Destruction of Property (self)
Destruction of Property (others)
Disrobing in Public
Hoarding
Intentional urination/defecation
Public Masturbation
Inappropriately Touching Self
Inappropriately Touching Others
Odd Behavior (explain)
Spitting
Withdrawal
Tantrum
Eating Inedible Items
Pestering others
Invading others' personal space
Stealing
Other (explain below)
If you selected 'other,' please provide explanation of behavior:
Antecedent- What happened BEFORE the behavior occurred?
Just arrived to area
Just left the area
Change in staff
Contact with family (visit, call, etc.)
Meal time
Medication administration time
Desired object present but unattainable
Difficult or non-preferred task presented
Moving from one activity to another
Persons preferred activity interrupted
Other person present/receiving more attention
Seizure
Toileting accident
Asleep/in bed
Physically attacked by another person
Verbally attacked or berated by another person
Personal property was taken
Denied want or told "no"
Delayed want/need
Space was invaded
Environment loud or hostile
Unfamiliar environment
Argument with staff or peers
Other (explain below)
If you selected 'other,' please provide explanation of antecedent:
How did you IMMEDIATELY respond to the behavior?
Ignored behavior
Attempted Safety Care de-escalation techniques
Practiced correct way to perform task
Suggested prescribed medication
Called for crisis intervention
Encouraged client to talk about problem
Suggested leisure activity for distraction
Returned client to their home
Called supervisor for assistance
Changed environment
Reminded of behavior contract or positive behavior rewards
Verbal redirection
Called 911, police, or emergency services
Placed client in predetermined non-violent restraint according to Safety Care training
Other (explain below)
How did you additionally respond to the behavior?
Completed behavior report (this form)
Documented behavior on Therap
Called supervisor to report behavior
Administered medication
Took client to emergency room or hospital
Scheduled appointment with primary care physician for follow-up
Scheduled appointment with mental health professional for follow-up
Other (explain below)
If you selected 'other,' please provide explanation of how you responded to behavior:
Incident Description (MUST COMPLETE FULLY)- Describe the incident in detail, including the time before, during, and after the incident. Include where the incident happened, what led to the event, and all parties involved. Note any threat to the person's health and safety or their peers/staff health and safety. Include how and when you notified your supervisor, the level of severity of the incident, and how/if the incident was resolved. Note if crisis intervention was needed.
Direct Care Staff Signature
Client Signature
Supervisor Signature
Submit
Should be Empty: