EDLC 623
Page 1 of 21
FUNCTIONAL EHAVIOR SSESSMENT B A TEMPLATE
Student’s Name: Jill Smith
Gender: Female
Interviewer: Anna Stewart
A. DESCRIBE THE BEHAVIORS
1. For of the behaviors of concern, define the topography (how it is performed), frequency EACH
(how often it occurs per day, week, or month), duration (how long it lasts when it occurs), and
intensity (how damaging or destructive the behaviors are when they occur). You must include at
least three behaviors on this list. You are NOT required to provide behaviors for rows D-J.
Behavior:
Provide a name
for the behavior
Topography:
How is the
behavior
performed?
Frequency:
How often
does the
behavior
occur?
Duration:
How long
does each
behavior
episode
last?
Intensity: Mild, moderate,
severe
a. Slapping
This behavior
starts by
hitting/slapping
herself and will
gradually move
to
hitting/slapping
herself in the
head.
Once per day
This
behavior
last until Jill
is able to
calm herself
down or
until she
removes
herself from
the
situation.
Severe/High Damage.
b. Crying
When Jill
becomes
agitated or upset
this behavior
starts.
Daily
Jill will
usually
have to be
removed
from the
situation or
the situation
has ended.
Mild/Non destructive.
c. Headbanging
This behavior
starts when Jill
is upset and will
bang her head on
the desk.
Two-Three
times per
week
Jill will
continue to
do this
behavior
until she has
clamed
down from
the situation
or she has
been
removed
from the
situation.
Severe/High
Damage/Destructive.
EDLC 623
Page 2 of 21
d. Hitting
Others
This behavior
happens when
Jill is engaged
by slapping
herself.
One-Two
times per
week
Jill will
continue
with this
behavior
until she is
removed
