Behavioral Intervention Plan Form

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Behavioral Intervention Plan Form Powered By Docstoc
					                                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?

 1st Occurrence—

 2nd Occurrence—

 3rd Occurrence—
Crisis Plan
How will an emergency situation or behavior crisis be handled? (Define possible scenarios, including the use of in-
school 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
ehavior

				
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posted:6/17/2012
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