Behavioral Intervention Plan Form

Behavioral Intervention Plan Form

Name: Date:

School: ______Grade: ______

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 how the student will be taught the skills needed for behavior modification, and provisions for monitoring progress and crisis management.

Problem Behaviors: Frequency: Intensity: Duration:

General Academic Issues:

__work is too hard

__not enough practice

__not enough help

__not generalized skill

General Behavior Issues:

__Lacks ability to perform expected behavior

__needs practice or modeling

__Requires more structure

__Cannot apply across settings

General Communication Issues:

__to request assistance

__to request a break

__to indicate a need

__to indicate frustration

FUNCTIONS of the Behaviors: 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:______

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 behaviors? 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?
Crisis Team: For behaviors that threaten the safety of the child or of others, the Crisis Team will be called and procedures implemented as per Policy 4373.
Monitoring of Behaviors (How the behaviors will be assessed and evaluated):
What data will be collected:
How it will be collected:
Who will collect it: Case Manager, ______
How will parents be notified of progress:
Date the plan will be reviewed:______

Signature of Parent: ______Date: ______

Signature of Staff:

I have reviewed this behavior intervention plan and am knowledgeable of my duties in its implementation.

Administrator:______Date:______

Regular Educator:______Date:______

Special Educator: ______Date:______

Other: ______Date:______

Other: ______Date:______