Behavioral Intervention Plan Form

advertisement

Behavioral Intervention Plan Form

Name: Date:

School: __________________________ __ DOB: ____ CIF: _____

This

Behavioral Intervention Plan

(BIP) is being created in response to exhibited persistent and/or severe behavior that 1) interferes with the student’s learning or the learning of others and 2) warrants interventions to positively redirect the targeted behavior. This BIP identifies the type and cause of the behavior, the replacement behavior, positive interventions and support to reinforce the replacement behavior, and appropriate consequences. The plan defines a how the student will be taught the skills needed for behavior modification, and provisions for monitoring progress and crisis management.

Problem Behavior (As described in FBA):

Frequency:

Intensity:

Duration:

Is this behavior a:

__Performance Deficit—is student able to perform the expected behavior?

__Skill Deficit—

Academic

__work is too hard

__

not enough practice

__not enough help

__not generalized skill

Behavior

__Lacks ability to perform expected behavior

__needs practice or modeling

__Requires more structure

__Cannot apply across settings

Communication

__to request assistance

__to request a break

__to indicate a need

__to indicate frustration

FUNCTION (cause) of the Behavior:

What purpose does the identified behavior(s) seem to serve for the child?

Escape ____

_____Avoid a demand or request

_____Avoid an activity

_____Avoid a person

_____Escape the school

_____Other ________

Sensory/Perceptual____

_____Automatic sensory stimulation

_____Perceptual reinforcement

Attention/ Control_____

_____Gain adult attention

_____Gain peer attention

_____Get sent to a preferred adult

_____Other ______________

Gain Desired Item______

_____Get desired item/activity/area

_____List:______________________

Hypothesis:

The function of the behavior is to

Intervention Strategies

1. Environment

and/or

Circumstances

How can the environment or circumstances that trigger the behavior (or the result of it) be adjusted?

Staff Responsibility:

Student Responsibility:

2. Curriculum

and/or

Instruction

What changes in the curriculum and/or instructional strategies will be helpful, and who will make it happen?

Staff Responsibility:

Student Responsibility:

3. Other Strategies or Positive Supports (including school personnel, peers, or family)

Staff Responsibility:

Student Responsibility:

Desired Replacement Behavior

What behavior will be taught to replace the targeted behavior? How will it be taught/re-taught/reinforced, and by who?

Rewards and/or Motivators

How will the student be reinforced so that the replacement behaviors are more motivating than the problem behavior?

Consequences

What consequences will be implemented for repeated occurrences of the problem behavior?

1 st

Occurrence—

2 nd

Occurrence—

3 rd

Occurrence—

Crisis Plan

How will an emergency situation or behavior crisis be handled? (Define possible scenarios, including the use of inschool or out-of-school suspension, or aversive techniques, as appropriate)

Monitoring of Behavior (

How the behavior will be assessed and evaluated):

What data will be collected:

How it will be collected:

Who will collect it: Case Manager, ______________________

Date the plan will be reviewed:

_________________________

Adapted from the

New Mexico Public Education Department Technical Assistance Manual: Addressing Student Behavior

Download