Moment By Moment Assessment for Caregivers
Child’s name:______Date completed:______
Date and time of incident:______Person completing form:______
Please gather information from all possible observers.
JUST BEFORE THE EPISODE
1.) How was the child looking emotionally just before the melt-down or incident?
Calm Happy Excited Agitated Angry Sad Other:______
2.) What was the child doing behaviorally before the incident?
Resting Eating Playing Learning Talking Transitioning from one activity to another Watching something Cleaning Other:______
3.) What did the child seem to be focused on or thinking about?
4.) What appeared to trigger the child’s melt-down?
Voice Image Smell Loss of something Being asked to do something
Body contact (touch) Criticism Discipline Limit setting Other:______
5.) Who appeared to initiate the trigger?
Mother Father Stepparent (M or F) Resource Parent Sibling Relative Teacher Peer Stranger Clinician Other:______
6.) Where did the incident occur?
Home School Neighborhood Car/Bus Office Other:______
DURING THE EPISODE
7.) What emotion did the child display?
Sad Fear/Panic Anger/Rage Guilt/Shame Numb/spaced out Flashbacks Grief Physical symptoms Other:______
8.) What was the child doing behaviorally during the incident?
Raising Voice Swearing at others Hitting Kicking Biting Throwing things Breaking or damaging property Harming self Talking about suicide Using substances
Running away Eating disturbance Sexually impulsive or engaging in boundary violations Theft Other:______
9.) What did the child seem to be focused on or thinking about?
AFTER THE EPISODE
10.) What emotions did the child display?
Sad Fear/Panic Frustrated Guilt/Shame Grief Calm Other:______
11.) What was the child doing behaviorally after the incident? ______
10.) How long did it take the child to return to baseline?______What did the child do when he/she had calmed down?______
11.) From your direct observations of this child, if you could name one thing you think is bothering this child the most at this time what would it be? ______