Parent’s Name: ____________________ Date: _________
Child’s Name: ____________________ Date of Birth: ________ Age: ____
1. Which of the following skills does your child need help with? (check all that apply)
a. Social Skills:
___ increasing eye contact
___ playing near other children
___ playing with other children
___ sharing/turn-taking
___ waiting
___ remaining calm in groups
___ other:
b. Communication Skills:
___ following simple directions
___ letting you know when he/she wants something (e.g. food/toy)
___ letting you know when he/she wants you to do something (e.g. play)
___ letting you know when he/she doesn’t want something
___ letting you know when he/she wants your attention
___ letting you know when he/she is enjoying something
___ other:
c. Flexible Behavior:
___ tolerating changes in routines
___ trying new things
___ tolerating changes in activities
___ playing with toys better
___ reducing self-stimulatory behavior
___ other:
2. Which of the following behaviors are a concern to you at the present time? (check all that apply)
___ tantrums
___ screaming/crying
___ hurting others
___ destroying objects
___ throwing objects
___ wandering off
___ using his/her body in unusual ways
___ not responding to “no”
___ conflicts with siblings
___ tuning you out
___ taking toys/objects from other children
___ other:
3. Why do you think your child behaves in this way?
4. Which of the following statements best describes the impact of your child’s behavior on your family:
___ My child’s behavior does not interfere with our family’s daily routine.
___ My child’s behavior interferes somewhat with our family’s daily routine.
___ My child’s behavior interferes significantly with our family’s daily routine.
5. Which of the following strategies have you tried at home to manage your child’s behavior?
___ praising good behavior
___ providing special rewards for good behavior
___ making events predictable for your child
___ ignoring bad behavior
___ scolding your child for bad behavior
___ time-out after bad behavior
___ restricting privileges after bad behavior
___ physical punishment (e.g., spanking)
___ providing visual cues to aid understanding
Other strategies employed:
6. How effective were these techniques in changing the behaviors your were concerned about?
7. What would you like to gain most from a workshop on behavior management?
