Problem Behavior Information

1. Problem behavior (check and describe):

_Aggression

_Self-Injury

_Stereotypy

_Property destruction

_Other

2. Frequency: _Hourly_ Daily_ Weekly_ Less often

3. Severity: _Mild: Disruptive but little risk to property or health

_Moderate: Property damage or minor injury

_Severe: Significant threat to health or safety

4. Situations in which the problem behavior is most likely to occur:

Days/Times ______

Settings/Activities _________

Persons present _______

5. Situations in which the problem behavior is least likely to occur:

Days/Times_____

Settings/Activities ________

Persons present ___________

6. What is usually happening to the person right before the problem

behavior occurs?_________

7. What usually happens to the person right after the problem

behavior occurs?____________

8. Current treatments____________