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SORBC Information Form
Please complete this form to provide information to direct our behavior supports consultation.
(This information is confidential)
* Indicates required question
Your First & Last Name
*
Your answer
Your relationship to the Child or Individual you're completing this form for.
*
Your answer
Your Email & Phone Number &
the best way to reach you after you have completed this form.
*
Your answer
The Child or Individual's First & Last Name
*
Your answer
The Child or Individual's pronoun preference (He/She/They/Them)
*
Your answer
The Child or Individual's email & phone number
Your answer
Child/Individual's Date of Birth
*
MM
/
DD
/
YYYY
Please list who the Child/Individual currently resides with. Include their name and relationship please:
*
Your answer
Child/Individual's Disability/ies
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Your answer
Please list all concerns for the Child/Individual in the school or vocational setting:
*
Check all that apply
No Concerns at this time
They do not attend a school/vocational setting
Refusal - School refusal or work refusal - refusal to complete tasks
Refusal to go or attend
Social Problems - gets into arguments
Social problems - doesn't initiate or maintain relationships
Social problems - doesn't get along with staff
Academic struggles (reading/writing/math)
Focus/Attention/Distracted easily
Safety - doesn't stay in designated area
Safety - is unsafe with inanimate objects
Safety - is unsafe with others
Safety - is unsafe with self
Hates school or site
I'm not sure what the problem is
Other:
Required
Please list all concerns for the Child/Individual in social settings outside of the home.
*
Check all that apply
No Concerns at this time
They are not able to be in social settings at this time
Refusal to go or attend
Social Problems - gets into arguments
Social problems - doesn't initiate or maintain conversations
Social problems - doesn't get along with care providers when in public
Social problems - responds too friendly to strangers in public
Social problems - is too loud in public settings
Social problems - responds too shy to strangers in public, avoids people
Academic struggles - Reading information, or money skills are a problem in public
Focus/Attention/Distracted easily - doesn't stay on task, is bored easily or moves on quickly
Safety - doesn't stay in designated area
Safety - is unsafe with inanimate objects
Safety - is physically unsafe with others
Safety - is sexually unsafe with others
Safety - is verbally unsafe with others
Safety - is unsafe with self
Safety - is unsafe with animals
Settings - doesn't like the sites we go to
Settings - is uncomfortable when it's busy or loud
Settings - is uncomfortable when its hot or cold
Settings - is uncomfortable with lighting
I'm not sure what the problem is
Other:
Required
Please list all concerns regarding the Child/Individual at home:
*
Check all that apply
No Concerns at this time
Schoolwork refusal
Chore refusal
Kitchen safety
Food safety
Over or under eating
Bathroom safety
Outside safety
Safety in their bedroom
EVERYTHING SAFETY... ugh!
Getting along with their siblings
Getting along with another family member or care provider
Focus/Attention/Distracted easily
Struggles to share
Refusal to leave the house
Disruptive
Verbally unkind to others
Physically harms others
Harms animals
Harms inanimate objects
Indiscriminate object dumping - throwing items off shelves, etc.
Other:
Required
With our support, these are still difficult:
*
Verbally harms self
Physically harms self
Does not have good hygiene
Sleep/sleeping
Eating/food
Refuses to take medications
Medication side effects
Struggles to Self-Calm or Self-Soothe
Sexual concerns
Other:
SOME TOUGH QUESTIONS IN HERE. Please list all that apply:
*
None apply
Have a prior behavior plan
Have a prior/current IEP or 504 (if you don't know what this is, don't check it)
Have a prior safety plan
Have a history of self harm
Have had a brain injury or have been hospitalized for a concussion
Have harmed others
Have said they wanted to die and meant it
Have a history of attempting suicide
Have an abuse history
Have a history of being taken advantage of
Have a history of stealing
Have a history with jail or the police
Have a drug abuse history
Other:
Required
Please list anything that has been missed or explain anything that has been checked that you would like to share more about:
After I receive your response, I will get back to you to schedule time to discuss your concerns. Thank you for your time. ~December Tueller, Behavior Consultant
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