Behavior Consult Form

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Directions: This form is designed for school personnel to initiate the process of a behavior consult. Responses are provided by the concerned teacher or those school personnel who come in contact with the student most often throughout the school day. The purpose of these responses is to gain a better understanding of the specific features of the behavior that have prompted a consult. Please be as clear and concise as possible.

**(If you have any additional behavioral data, please email the data to Sarah Nordstrom at sarah.nordstrom@k12.sd.us)

Today's Date *

YYYY

Staff Name *

School Name *

Student Name *

Student Grade *

Is the student an Exceptional Education Student? If so, what is their disability category? *

Is the student in the process of an evaluation or academic SST? *

1. What is the reason for requesting behavioral help? *

2. Please provide a description of the behavior(s). Consider what the behavior looks like, how often it occurs, and how long it usually lasts. *

3. Have you noticed anything that typically occurs prior to the behavior(s)? *

*Antecedents or triggers

Denial or Delay

Instructions/Task Demands/Requests

Lack of Structure

Transitioning

Presence or Close Proximity and Interactions of Others

Change of Routine or Expectation

Lack of Active Engagement/Reduced Attention

Consequence Induced

Other:

Required

4. How do the students' peers typically respond when the behavior occurs? *

5. How do staff typically respond when the behavior occurs? *

6. What specific behaviors is the student expected to demonstrate at the time? *

Example: complete a task or follow a direction

7. Are there any specific events or individuals present when the behavior occurs? And/or do they occur only during a certain time of day? *

8. Why do you think the student is behaving this way? *

*Function(s) if other add notes in additional comments

To gain attention from peers or staff

To gain access to items/activities or locations

To escape or avoid instructions/task demands

To escape or avoid peers or staff

To gain access to a sensory stimulus

To escape or avoid a sensory stimulus

Other:

Required

9. Please list any potential reinforcers for the student *

10. Is there anything that is currently working well for the student? *

11. What are the student's strengths? *

12. Are you concerned for the safety of the student or safety of others while at school? *

If you answer yes to either, please add why in the additional comments below.

Yes, for the students safety

Yes, for the safety of others

Yes, for the safety of the student and others

13. Any other relevant information you would like to share with the team?

*Additional Comments, (if the student has an informal or formal plan in place, please also email it to Sarah Nordstrom: sarah.nordstrom@k12.sd.us)

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