FBA Parent Interview
Parent Interview
Student Name ______________________________ Age _______ Grade _________
Birthdate ______________________ Date of Interview __________________________
Person Conducting Interview _______________________________________ __________
A. Child’s Medical History
1. Are there any medical issues about your child you believe are important?
2. Is your child currently taking any medication? If so, please list type and dosage.
3. Has your child had previous testing or psychological examinations? If so, please provide date, agency and
summary of the results.
B. Psychological and Social History
1. Please describe the kinds of activities in which your child engages in the neighborhood and in the home.
2. Have there been any unusual changes or events recently in the home?
3. Is there any evidence of emotional tension, fear, irritation, or lack of confidence in your child?
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FBA Parent Interview
C. Social and Behavior Checklist
Place a check next to any behavior or problem that your child currently exhibits.
Withdrawn Shows daredevil behaviors
Has low self-confidence Gives up easily
Has low motivation Poor self-expression
Gets along with parents Prefers to be alone
Gets along with teachers Sucks thumb
Gets along with peers Bites fingernails
Gets along with siblings Eats poorly
Is aggressive Has poor bowel control
Is shy or timid Is much too active
Has frequent tantrums Is stubborn
Has frequent nightmares Is clumsy
Has trouble sleeping Has blank spells
Wets the bed Is impulsive
Is more interested in things and objects Engages in behavior that could be dangerous
than people to self or others
Other
1. Of the above, which behavior is of greatest concern to you?
2. Briefly describe your child’s current difficulties.
3. How long has this problem existed?
4. What seems to help the problem?
5. What seems to make the problem worse?
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FBA Parent Interview
D. Educational Concerns
1. What do you perceive to be your child’s strengths at school?
2. How do you believe these problems can be best addressed?
3. Does your child seem to be experiencing difficulty at school? If so, please describe.
4. What do you see your child doing as an adult?
5. How do you believe that school can help your child reach this goal?
6. Do you have any additional comments/concerns regarding your child’s education?
E. Disciplinary Techniques
1. What disciplinary techniques do you usually use when your child behaves inappropriately? Place a check next to
each technique that you use.
Ignore the problem Send your child to his/her room
Scold your child Take away some activity or food
Spank your child Reason with your child
Threaten your child Don’t use any technique
Redirect your child’s interest Other technique
Have your child sit on a chair
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FBA Parent Interview
2. What disciplinary techniques are usually effective?
3. What disciplinary techniques are usually ineffective?
4. What have you found to be the most satisfactory ways of helping your child?
5. Is there any other information that you think may help us in working with your child?
6. What are your child’s favorite activities?
7. What activities would you like your child to engage in more often than he or she does at the present?
8. What activities do your child like the least?
