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
___ remaining calm in groups
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
c. Flexible Behavior:
___ tolerating changes in routines
___ trying new things
___ tolerating changes in activities
___ playing with toys better
___ reducing self-stimulatory behavior
2. Which of the following behaviors are a concern to you at the present time? (check all that apply)
___ 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
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?