Healthcare Psych-FBA Form

Healthcare Psych-FBA Form

Patient Information

Patient Name:    Date of Birth:

Male    Female    Non-binary    Other:

Insurance / Payer

Referral & Assessment Context

Date of Referral:    Referring Clinician/Provider:

Behavior Description & Operational Definitions

Provide precise, observable, and measurable definitions for each target behavior. If multiple behaviors, number and define separately.

ABC (Antecedent-Behavior-Consequence) Observation Records

Record observed episodes with context. Include time, setting, antecedent events, exact behavior, and immediate consequence.

Functional Analysis / Hypothesized Function

Indicate suspected functions and provide justification based on observation and data.

Attention (social attention)    Escape/Avoidance (task demands, transitions)    Access to Tangibles/Activities    Sensory/Automatic Reinforcement

Medical, Developmental & Psychiatric History

Risk Assessment

Suicidal Ideation/Attempts: Yes    No

Aggression / Harm to Others: Yes    No

Previous Interventions & Response

Strengths, Preferences & Supports

Clinical Summary & Formulation

Provide a concise synthesis of assessment findings, hypothesized function(s), and clinical impressions.

Recommended Interventions / Behavior Plan Components

Authorization & Privacy Acknowledgment

By signing below, I authorize clinicians to conduct the functional behavioral assessment described above, to access relevant records, and to share assessment findings and a resulting behavior plan with indicated treatment team members and educational staff as necessary for treatment planning and safety. I understand that confidentiality will be maintained except where disclosure is required or permitted by law, including reporting of suspected abuse or where there is an imminent risk of harm to self or others.

I understand that I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it. This authorization will expire on:

I acknowledge receipt of a privacy notice describing how protected health information may be used and disclosed in relation to this assessment. I understand that participation in assessment is voluntary and that refusal may affect the provision of recommended services.

Clinician Information (for record)

Acknowledgment & Certification

I certify that the information I have provided on this form is accurate to the best of my knowledge. I authorize the performance of the functional behavioral assessment and related observations described in this document and permit reasonable information exchange among members of the treatment and educational team for the purpose of developing and implementing a behavior intervention plan.

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