FBA Parent Questionnaire

Functional Behavior Assessment — Parent/Guardian Input

A Functional Behavior Assessment (FBA) gathers information about behaviors of concern — whether academic, social, or emotional. Your responses help the evaluation team understand your child and create effective, personalized support.

Student & Contact Information

Student's Name (First and Last) *

Today's Date *

Your Name (Relationship to Student) *

Best Phone / Email *

About Your Child

What are your child's strengths? *

What is your child interested in? Do they have hobbies? *

What motivates your child? What will they work for? * e.g. iPad, tech, LEGOs, going on a walk, talking, drawing

Behavior of Concern

What behaviors are getting in the way of your child being successful in school? *

How often do these behaviors occur, how long do they last, and how intense are they? * e.g. 3–4 times a day, lasting about 10 minutes, very disruptive

Triggers & Setting

What things "set the stage" for behavior to occur? * e.g. conflicts at home, homework not done, hunger, illness, missed medication

When is behavior MOST LIKELY to occur? *

When is behavior LEAST LIKELY to occur? *

What should be AVOIDED so that behaviors do not occur? *

Calming & Self-Regulation

What works to help calm your child or helps them self-regulate? *

Is there any additional information you would like to share?

Signature

Parent / Guardian Signature *

Date *