QABF – Bardin Behavioral Health, LLC

QABF Client Information

Date

Initials of child/adult *

Email *

Phone

Name of person completing this form *

Behavior of interest (please be specefic: i.e. if aggression occurs in multiple enviornments, answer the questions below for aggression in one of the two enviornments) *

QABF Questions

1. Engages in the behavior to get attention. *

2. Engages in the behavior to escape work or learning situations. *

3. Engages in the behavior as a form of “self-stimulation". *

4. Engages in the behavior because he/she is in pain. *

5. Engages in the behavior to get access to items such as preferred toys, food or beverages. *

6. Engages in the behavior because he/she likes to be reprimanded. *

7. Engages in the behavior when asked to do something (brush teeth, work, etc.) *

8. Engages in the behavior even if he/she thinks no one is in the room. *

9. Engages in the behavior more frequently when he/she is ill. *

10. Engages in the behavior when you take something away from him/her. *

11. Engages in the behavior to draw attention to him/herself. *

12. Engages in the behavior when he/she does not want to do something. *

13. Engages in the behavior because there is nothing else to do. *

14. Engages in the behavior when there is something bothering her/him physically. *

15. Engages in the behavior when you have something he/she wants. *

16. Engages in the behavior to try to get a reaction from you. *

17. Engages in the behavior to try to get people to leave him/her alone. *

18. Engages in the behavior in a highly repetitive manner, ignoring this/her surroundings. *

19. Engages in the behavior because she/he is physically uncomfortable. *

20. Engages in the behavior when a peer has something he/she wants. *

21. Does he/she seem to be saying “come see me” or “look at me” when engaging in the behavior? *

22. Does he/she seem to be saying “leave me alone” or “stop asking me to do this” when engaging in the behavior? *

23. Does he/she seem to enjoy the behavior, even if no one is around? *

24. Does the behavior seem to indicate to you that he/she is not feeling well? *

25. Does he/she seem to be saying “give me that (toy, item, food)” when engaging in the behavior? *

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Questions about Behavior Function (QABF)

QABF Client Information

QABF Questions