Office of Developmental Disabilities
Stabilization and Crisis Unit
Functional Assessment/Behavior Support Plan
Client name:
Revised:
Date of plan:
Revised:
Revised:
Revised:
Revised:
I. Client profile
Individuals interviewed and/or consulted for the Assessment Plan:
Revised:
Date interview
process is started:
Use this date on RTRs, ect.
Client identifying information:
Psychosocial history:
Review of dangerous behaviors:
Below add sections and add the name and specific behaviors as needed.
Name of behavior
1.
Frequency:
Context:
Duration:
Intensity/severity:
Interferes with community or social participation
Interferes with skill acquisition or other activities
Name of behavior
Threatens the safety of others or infringes on the rights of others
Is a risk to the health or safety of self
2.
Frequency:
Context:
Duration:
Intensity/severity:
Interferes with community or social participation
Interferes with skill acquisition or other activities
Threatens the safety of others or infringes on the rights of others
Is a risk to the health or safety of self
Contributing medical conditions that may have an impact on an individual’s behavior(s):
.
How the mental health diagnosis manifests in the individual:
II. Client needs, preferences, relationships
Needs:
Policy #3.001 Attachments B & C FA/BSP
Page 1 of 4
DHS 4588 Blended Plan (08/14)
Preferences:
Relationships:
Expressive communication:
Receptive communication:
Communication in distress:
III. Behavior definitions
Behaviors to increase:
Behavior to increase
1.
Define:
Data collection:
Behavior to increase
2.
Define:
Data collection:
Behaviors to decrease:
Some have similar or the same “Triggers”: Used to support client in
learning how to express his concerns in an appropriate manner.
Elaborate in first reference similar “Triggers” and “Precursors.” Check box if different and explain.
Setting events:
Triggers:
Precursors:
Name of behavior
1.
Definition:
Trigger same first reference
Trigger different, explain:
Precursor same first reference
Precursor different, explain:
Setting event same first reference
Setting event different, explain:
Trigger same first reference
Trigger different, explain:
Precursor same first reference
Precursor different, explain:
Setting event same first reference
Setting event different, explain:
Data collection:
Alteration criteria:
Name of behavior
2.
Definition:
Data collection:
Alteration criteria:
IV. Behavior functions
Behavior chains / response classes:
Policy #3.001 Attachments B & C FA/BSP
Page 2 of 4
DHS 4588 Blended Plan (08/14)
Function of behavior(s):
Functional alternatives to behavior(s):
Incentive plan:
Not applicable
V. Proactive strategies
Crowded community events
(fairs)
Restaurants
Parks
Stores
Yard
Laundry room
Living / dining room
Kitchen
Bathroom
Asleep: Bedroom
Check if applicable
Awake: Bedroom
Supervision levels (general):
Not allowed in room
3 - feet
10 - feet
In the same room
Visual contact at all times
15 – minute visual checks
30 – minute visual checks
Hourly visual checks
Check visual every 2 - hours
Other:
Supervision levels (other):
Other:
Other:
Other:
Other:
Other:
Other:
Other:
Other:
Other:
Other:
Other:
Check if applicable
Not allowed in room
3 - feet
10 - feet
In the same room
Visual contact at all times
15 – minute visual checks
30 – minute visual checks
Hourly visual checks
Check visual every 2 - hours
Other:
General staff interaction guidelines:
Policy #3.001 Attachments B & C FA/BSP
Page 3 of 4
DHS 4588 Blended Plan (08/14)
Community access:
Community restroom procedure:
Outing requests:
Other:
VI. Reactive strategies
General:
Community:
VII. Crisis strategies – BSP essential components
1)
General:
2)
Program approved PPI’s:
3)
When to abort the PPI:
PPI release criteria:
VIII. Recovery strategies
IX. Assessment summary of recommendations:
X. Author:
Policy #3.001 Attachments B & C FA/BSP
Page 4 of 4
DHS 4588 Blended Plan (08/14)