Professional Behavior Services Referral Form

Professional Behavior Services Referral Form

Please complete this referral form to request Professional Behavior Services, such as Functional Behavior Assessments, Positive Behavior Support Plans, consultation, or caregiver coaching. Referrals may be submitted by case managers, service coordinators, school staff, or parents/guardians. We will follow up within 3–5 business days after submission.
Referral Source
Parent / GuardianCDDP Service CoordinatorBrokerage Personal AgentSchool StaffMedical ProviderTherapist / ProviderOther
Name of person completing this form*
Organization / Agency (if applicable)
Email address*
example@example.com
Phone number*
Please enter a valid phone number.Format: (000) 000-0000.
Client Information
Client full name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Client age*
Primary language spoken at home
Home address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent / Guardian Information
Parent / Guardian name
Parent / Guardian email
example@example.com
Parent / Guardian phone number
Please enter a valid phone number.Format: (000) 000-0000.
PhoneEmailEither
Case Management Information
Case worker / service coordinator name
Agency
Case worker email
example@example.com
Case worker phone number
Please enter a valid phone number.Format: (000) 000-0000.
Services Requested
Functional Behavior Assessment (FBA)Positive Behavior Support Plan (PBSP)Behavior consultationParent / caregiver coachingOther
Is the individual eligible for Developmental Disabilities services and currently receiving services in Oregon?If applicable, are behavioral consultation hours added to the Functional Needs Assessment or approval updated in eXPRS?Private PayUnsure
Behavioral Concerns
Please describe the behaviors of concern (e.g., aggression, self-injury, elopement, property destruction, refusal, or other safety concerns)*
HomeSchoolCommunityMultiple environments
Multiple times per dayDailySeveral times per weekWeeklyOccasionally
YesNo
Please describe safety concerns*
Diagnosis and History
AutismADHDIntellectual DisabilityAnxiety DisorderNo diagnosisUnsureOther diagnosis
YesNoUnsure
Please describe previous services*
Additional Information
Urgent (safety concerns)Within 1–2 monthsFlexible
Should be Empty:

Professional Behavior Services Referral Form

Referral Source

Client Information

Parent / Guardian Information

Case Management Information

Services Requested

Behavioral Concerns

Diagnosis and History

Additional Information