Christian Children’s Home of Ohio
BEHAVIORAL INTERVENTION PLAN
Resident: ________________________________
DOB: ______________ Date Plan Developed: _________
DOP: ___________________ Preliminary Diagnosis: ____________________________________________
BEHAVIORS – Check any behaviors client has exhibited within the last 3-6 months:
☐ Physical aggression
☐ Suicide threats
☐ Appetite disturbance
☐ Lying
☐ Sexual aggression
☐ Self-injurious behaviors ☐ Mood disturbance
☐ Enuresis
☐ Verbal aggression
☐ Alcohol use
☐ Fire setting
☐ Encopresis
☐ Auditory hallucinations ☐ Drug use
☐ Cruelty to animals
☐ Stealing
☐ Visual hallucinations
☐ Running away
☐ Sleep disturbance
☐ Other
Other: ___________________________________________________________________________________
TRIGGERS
☐ Bedtime/Darkness
☐ Bathrooms
☐ Men
☐ Yelling
☐ People to close
☐ Not being listened to
☐ Lack of privacy
☐ Darkness
☐ Feeling lonely
☐ Being teased
☐ Being told “No”
☐ Being confronted
☐ Arguments
☐ Being isolated
☐ Loud noises
☐ Not having control
☐ Women
☐ Being stared at
☐ Being hit
☐ Being yelled at
Other: ___________________________________________________________________________________
EARLY SIGNS OF ESCALATION
☐ Face turns red
☐ Tightness in chest
☐ Restless/Agitated ☐ Sweating
☐ Pacing
☐ Clenching teeth
☐ Shortness of breath ☐ Clenching fists
☐ Bouncing legs
☐ Shaking
☐ Crying
☐ Using a loud voice
☐
☐ Rocking
☐ Swearing
☐ Becoming aggressive
☐ Upset stomach
☐ Other
Other: ___________________________________________________________________________________
INTERVENTIONS:
Type of interventions which client may use to de-escalate (Check below all that apply.)
Interventions not checked are contra- indicators and may not be used.
☐ Physical proximity ☐ Breathing relaxation
☐ Use of diversion ☐ Verbal de-escalation
☐ Reminder charts ☐ Taking a “Time-out”
☐ Listening to music ☐ Writing/drawing
☐ Separate from the group ☐ Verbal direction
☐ Problem solving
☐ Exercise
☐ Reading
☐ Take a walk
☐ Putting hands in cold water ☐ Other
Other: ___________________________________________________________________________________
Rev 8/24/2015
Resident: ________________________________
PSYCHOLOGICAL or DEVELOPMENTAL CONCERNS/CONTRAINDICATIONS:  YES or  NO

Abuse Victim: ______________________________

MRDD: _____________________________

AWOL Risk: _______________________________

Neglect Victim: _______________________

Disciplinary Problem: ________________________

Complaints or Adjudicated Felonies against Child: ___________________________________________
MEDICAL CONCERNS:  YES or  NO
Medical Contraindications:

Respiratory System: _____________________________________________________

Circulatory System: _____________________________________________________

Neurological System: ____________________________________________________

Muscular Skeletal: ______________________________________________________

Gastro: _______________________________________________________________
Special Precautions: _______________________________________________________
________________________________________________________________________
Health Care Professional: ______________________________________ Date: _______________________
Type of restraint which may be used (Check below all that apply.) 
Interventions not checked are contra- indicators and may not be used.
Type of Restraint
sgl
mult
sgl
Extended arm assist
Upper torso assist
Use of physical restraints
mult
sgl
Seated kneeling cradle assist
Crossed arm assist
Supine torso assist
Seated kneeling upper torso assist
Standing biceps assist
Side assist
Seated kneeling biceps assist
Cradle assist
Hook transport
2 person supine extension assist
Shoulder assist
Cradle Transport
3 person supine extension assist
Rev 8/24/2015
mult
_________________________________
Clinician/ Practitioner of Behavioral Science (must be LSW, LISW, LPC, LPCC)
Rev 8/24/2015
Date _____/_____/_____