Interview for Functional Evaluation Template

Background:
- Client Name: John Doe
- Date of Interview: 1 November 2024
- Respondent/s: Jane Doe (mother)
- What other support/therapy has he/she received in the past? John has previously participated in speech therapy and occupational therapy.
- Are there any physical/mental health concerns you would like to make us aware of? John has been diagnosed with ADHD and mild anxiety.
- Any other family circumstances you think may be relevant to inform us, i.e. number of siblings, changing living arrangements or routines across a week? Cultural identity? John has two siblings, and the family recently relocated to a new city.
- Who are the significant people in the person’s life? Has this changed? Significant individuals include his parents and his teacher, Mrs. Smith.
- Has the person experienced any known trauma? No known trauma.
- Other key people involved in person’s life and their willingness to collaborate? i.e. school, day program, support workers? His teacher and school counselor are involved and willing to collaborate.
- General Background Notes: John is generally a happy child but struggles with transitions.
Health and wellbeing:
- Medications: Methylphenidate for ADHD
- Prescribing doctor? Mention need to check for RP: Dr. Thomas Kelly, check for repeat prescriptions.
- Sleep patterns: John has difficulty falling asleep and often wakes up during the night.
- Diet/eating habits: Picky eater, prefers carbohydrates and avoids vegetables.
- Toileting: Fully toilet trained.
- Independent self-help skills – washing, dressing, cleaning, etc.: Needs assistance with dressing and washing.
Skills:
- Communication: how does the person communicate with those around them? John communicates verbally but struggles with complex sentences.
- Do they have the skills to follow spoken instructions? Can follow simple instructions but struggles with multi-step directions.
- Are there any barriers? Difficulty with attention and focus.
- Do they respond to signs/gestures from others? Yes, responds well to visual cues.
- Do they have the skills to imitate vocalisations? Yes, can imitate simple sounds and words.
- How do they indicate yes/no? Verbally says 'yes' or 'no'.
- Other life skills? Can use a fork and spoon independently.
- Social Skills/friends/relationships: Has a few friends but struggles with sharing and turn-taking.
- Reading/writing: Can read simple words and write his name.
- Counting: Can count to 20.
- Academic level of functioning (if applicable): Functioning at grade level in most subjects.
- Particular areas for improvement: Needs to improve focus and attention span.
- Responding to simple receptive instructions; no, wait, come here etc.: Responds well to simple commands.
Behaviours of Concern:
- Describe the behaviours of concern: John exhibits impulsive behaviour and occasional outbursts.
- How long has this behaviour been occurring? Since starting school.
- Rate the severity and impact to the individual/family/community of each BOC (1-5):
  - BOC: Impulsivity
  - Severity: 3
  - Frequency: 4
  - Impact: 3
  - Notes: Impulsivity affects his ability to complete tasks.
- To assist in identifying precursors to dangerous problem behaviours:
  - Do the different types of interfering behaviour tend to occur in bursts or clusters and/or does any type of problem behaviour typically precede another type of problem behaviour (e.g., yells preceding hits)? Impulsivity often precedes outbursts.
- To determine the antecedent conditions that may be incorporated into the functional analysis test conditions:
  - In what situations does the behaviour most occur?
    - Most Likely: During transitions between activities.
    - Least Likely: During one-on-one activities.
  - Time of day/month/year: Most likely in the afternoon.
  - Setting – where are they?: At school.
  - People – who is there?: Classmates and teacher.
  - Activities – what is the person doing?: Group activities.
  - Phrases/words – what is the person trying to communicate?: Often expresses frustration.
- To determine the specific type(s) of consequences that may be maintaining the behaviour:
  - Do you think the behaviour is effective? i.e. results in the person getting their needs met? 1-5 least to most effective: 2
  - What do you or others do when the behaviour occurs? Redirect and provide calming strategies.
- If you could create a situation where you will be almost guaranteed for the person to have their best day, with no interfering behaviours at all, …. where are they, who are they with, what are they doing, what does this look like? At home, with family, engaging in a favourite activity like building with blocks.
- How would the person respond to the following?
  - A Difficult Task: May become frustrated and require assistance.
  - When a desired activity is interrupted?: Likely to express frustration verbally.
  - When they experience unexpected change?: May become anxious and need reassurance.
  - When they could not get their needs met?: Likely to have an outburst.
  - When there is no attention or interactions from others?: May seek attention through disruptive behaviour.
- Identifying some potential reinforcers/preferences:
  - Preferred food and drink items?: Pizza and apple juice.
  - Preferred items (Toys/Objects): Building blocks and toy cars.
  - Preferred activities at home: Playing with blocks and watching cartoons.
  - Preferred activities in the community: Going to the park.
  - Other things that the person prefers?: Enjoys listening to music.