Client Behavior Questionnaire

Client Behavior Questionnaire

Client Behavior Questionnaire

This questionnaire helps us understand your child’s current behaviors, challenges, and strengths. Your detailed responses will assist us in creating an individualized treatment plan that best meets your family’s needs.
Email
example@example.com

Client & Parent Information
Client’s Full Name*
Date of Birth*

MonthDayYear
Date
Parent/Guardian Name*
Please Upload Recent Diagnosis Report

Cancelof

Behavioral Concerns
What are the main behaviors you are concerned about? (Examples: aggression, self-injury, tantrums, non-compliance, elopement, communication delays, etc.)*
How often do these behaviors occur?*
When are these behaviors most likely to occur?(Examples: during transitions, when denied access to items, during mealtime, etc.)*

Triggers & Antecedents
What situations or events typically trigger the challenging behaviors?*
Are there specific people, environments, or routines that seem to influence these behaviors?*

Current Strategies
What strategies or interventions have you tried in the past to manage these behaviors?*
Were any of these strategies effective? If yes, please describe.*

Reinforcers/Motivators
ToysSnacksElectronicsPraise/AttentionPhysical ActivitiesOther
If "Other" describe below*
Are there any specific rewards that you use successfully at home?*

Communication Skills
Verbal SpeechGestures/PointingSign LanguagePicture Exchange (PECS)Communication Device (AAC)Other
If "Other" describe below*
YesNoSometimes

Parent Goals
What are your short-term goals for your child’s behavior (next 6 months)?*
What are your long-term goals (next 12+ months)?*

Digital Signature
Parent/Guardian Signature (Type Full Name)*
Date of Submission*

MonthDayYear
Date
Should be Empty: