Motivation Assessment Scale
Date
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Month
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Participant's Name
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First Name
Last Name
Name of Respondent:
First Name
Last Name
Relationship:
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Describe the Behavior:
Frequency Scale: 0- Never, 1- Rarely, 2-Sometimes, 3-Often, 4-Always
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Rows
Answer
1. Would this behavior occur continuously if the client was left alone for long periods of time (ex. One hour?)
2. Does this behavior occur following a command to perform a difficult task?
3. Does this behavior occur when you are talking to other people in the room?
4. Does this behavior ever occur to get an object, activity food, or game that the client has been told he/she can't have?
5. Does this behavior occur repeatedly, over and over, in the same way? (ex. Rocking back and forth for five minutes)
6. Does this behavior occur when any request is made of the client?
.7 Does this behavior occur whenever you stop attending to the client?
8. Does this behavior occur when you take away a favorite object, activity, or food?
9. Does it appear your client enjoys performing this behavior and would continue even if no one was around?
10. Does the client seem to do this behavior to upset or annoy you when you are trying to get him or her to do what you ask?
11. Does the client seem to do this behavior to upset or annoy you when you are not paying attention to him or her? (ex. When you are sitting in a separate room, interacting w? another client.)
12. Does this behavior stop occurring shortly after you give the client the object activity, food he/she has requested?
13. When this behavior is occurring, does the client seem unaware of anything else going on around him or her?
14. Does this behavior stop occurring shortly after (one to five minutes) you stop working or making demands of him or her?
15. Does the client seem to do this behavior to get you to spend some time with him or her?
16. Does this behavior seem to occur when the client has been told that he/she can't do something he or she wanted to do?
Completed by:
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First Name
Last Name
Service Provider Email
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YourName@alltbi.com
Title:
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Signature of person completing Functional Assessment:
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Date
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Month
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Year
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