Behavior Consultant Assistance Request
Please be advised that the primary goal of this service is to coach the local district team in completing behavioral assessments and developing/implementing a plan to support the student in the CURRENT setting. It is important that all team members understand that no major changes (i.e. placement, addition of adult support) in student support should be made during the assessment phase. It is also important that any major changes in student support that are made during the later phases are done with function in mind.
Student's First Name
Student's Last Name
Student's Date of Birth
Student's School District
Brighton Area Schools
Fowlerville Community Schools
Hartland Public Schools
Howell Community Schools
Pinckney Community Schools
Student's IEP Eligibility
A signed Consent to Evaluate is on file
If Yes, what is the due date?
Directly observing student/collecting ABC data with the local team
Directly interviewing relevant staff with the local team
Analyzing ABC data with the local team to identify function
Co-creation of PBSP, supporting the team in integration of function based strategies
Modeling of function-based strategies
Along with local team, complete observations to check for implementation fidelity
Leading in the efforts to graph and analyze data
BEHAVIOR OF CONCERN
Definition of problem behavior
How long has the behavior(s) of concern been occurring?
List most recent dates of observation (date and observer)
Functional Behavioral Assessment (required)
Positive Behavior Support Plan (required)
Emergency Intervention Plan
Behavioral Data (progress monitoring related to current behavior plan, baseline data, scatter plot data, etc.)
Disciplinary/Office Referral Documentation
Manifestation Determination Review (MDR) Documentation
Attach documentation here.
CONSENT & ELECTRONIC SIGNATURE AGREEMENT OF REQUESTING PARTY
By selecting the "I Accept" button, you are acknowledging your willingness to participate in the behavioral consultation process and that you will remain the primary point person for scheduling meetings and communicating with the student’s team.
By selecting the "I Accept" button, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this document. You further agree that your signature on this document is as valid as if you signed the document in writing.
Requesting Party's Signature
Please type your First and Last Name here.
Requesting Party's Email Address
Please type your email address here.
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