Behavior Intervention Plan
Name:
Birthdate:
1.
Date:
School:
Identify and describe the challenging behaviors with the replacement behavior.
Target Behavior to be Changed
Description of Target Behaviors
Replacement Behavior
2. Identify proactive strategies to be used to prevent the behavior from occurring and to reinforce
replacement behavior.
Description of Proactive Strategies
Date Begun
Type of Data Collection
3. Crisis Plan: Describe the conditions and procedures that will be implemented if the student has a
crisis.
4. Describe any known risks, discomforts or side effects of behaviors.
5. Describe coordination activities with the family.
6. Process for review and evaluation by the IEP team.
7. Program Personnel Names and Titles of Persons Responsible for Implementation
Please initial name:
Name
Title
Setting III EBD Teacher
Program Para Professional
Program Para Professional
Behavior Intervention Staff
Social Worker
Occupational Therapist
Principal
5th Grade Teacher
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8. Informed Consent of Parent
Permission of this intervention plan is given by _______________________________________
Parent/Guardian Signature
On this date of ______________________________________
Date of Signature
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