Referral for Cooke School Dual-Diagnosed Program

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Email *

Student Name *

Date of Birth *

YYYY

Target behaviors identified on student's Behavior Intervention Plan (BIP) for which this student is being referred: *

Antecedent conditions to the problem/target behavior(s) (when, where, why, with whom, etc.). *

Motivation for behavior(s) (check one or more as applicable): *

Avoidance/Escape

Attention-Seeking

Self-Stimulatory

Tangible-Seeking

Other:

Required

List reinforcers the student responds well to and/or have been newly introduced as part of their BIP: *

List effective and somewhat effective strategies/interventions that are used with student. *

How often does the student engage in self-injurious behavior(s)? *

Does the student exhibit excessive dependence on adults? *

Does the student cry for insufficient or inappropriate reasons? *

Is the student inappropriately out-of-seat during class time? *

Does the student inappropriately verbalize to others (non-aggressive teasing, tattling, noises, interrupting, yelling)? *

Does the student exhibit physical aggression (hit, kick, bite, spit, grab)? *

Does the student exhibit verbal aggression (argue, swear, sexual comments, threaten, insults)? *

Does the student have a history of abusing/destroying property? *

Does the student throw temper tantrums? *

Does the student have a history of lying or stealing? *

Does the student exhibit inappropriate sexual behaviors ( public masturbation, touch/grope private parts of self or others, expose self)? *

Does the student refuse to comply with teacher/staff requests? *

Does the student have a short attention span? *

Is the student ever unpredictable (extreme mood changes, impulsive)?

Is the student ever apathetic or unmotivated? *

Is the student non-interactive with adults or peers (lack of eye contact, doesn't seek help when needed, no friends)? *

Does the student have phobic reactions to change or novelty? *

Does the student exhibit inappropriate behaviors (runs out of classroom/school, spits, urinates or defecates in clothes, smear feces, regurgitates) *

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