About this template
The Functional Analysis Screening Form is an essential evaluation tool used by occupational therapists, behavior analysts, and clinical specialists to assess and understand challenging behaviors in patients. By documenting the antecedents, behaviors, and consequences (ABCs) of specific actions, clinicians can identify patterns, environmental triggers, and underlying communicative functions of target behaviors to build effective, individualized treatment plans.
This comprehensive Google Form template streamlines clinical intake and behavioral observation by capturing key informant details, behavioral frequency, situational contexts, and social versus nonsocial reinforcement factors. Designed for seamless distribution, clinicians can easily share the assessment link with caregivers, teachers, or family members to gather vital observational data before clinical sessions.
Doc2Form makes it effortless to deploy and manage this screening template within your practice. Responses are instantly organized in Google Sheets, enabling multidisciplinary care teams to review findings, collaborate on intervention strategies, and maintain structured, paperless clinical records while saving valuable time during patient evaluations.
Key features
- Capture detailed ABC (Antecedent, Behavior, Consequence) data efficiently.
- Easily share screening links with caregivers, teachers, and family members.
- Streamline clinical intake and behavioral assessment workflows.
- Automatically organize observation notes and ratings in Google Sheets.
Use cases
Initial clinical intake assessments for behavioral therapy practices.
School-based behavioral observations and functional behavior assessme…
School-based behavioral observations and functional behavior assessments (FBAs).
Caregiver and family interviews regarding daily living challenges and…
Caregiver and family interviews regarding daily living challenges and behavioral patterns.
Multidisciplinary treatment planning for occupational and behavioral …
Multidisciplinary treatment planning for occupational and behavioral therapists.
What this form collects
- Client Full Name (Short answer)Enter the first and last name of the individual being assessed.
- Assessment Date (Date)Select the date this screening is being completed.
- Informant Full Name (Short answer)Enter your name if you are filling out this form on behalf of or regarding the client.
- Informant Relationship to Client (Dropdown)Select your relationship to the individual being assessed.
- How Long Have You Known the Client? (Short answer)Specify the duration of your interaction or relationship.
- Daily Interaction Status (Multiple choice)How frequently do you interact with the client on a daily basis?
- Problematic Behavior Description (Paragraph)Describe the specific behavior(s) of concern in clear, observable terms.
- Behavior Frequency (Dropdown)How often does this behavior typically occur?
- Most Likely Situations (Paragraph)In what specific situations or environments is the behavior most likely to occur?
- Least Likely Situations (Paragraph)In what situations or environments is the behavior least likely to occur?
- Antecedents (Events Before Behavior) (Paragraph)What typically happens immediately before the behavior occurs?
- Consequences (Events After Behavior) (Paragraph)What typically happens immediately after the behavior occurs (e.g., attention given, activity removed)?
- Part I: Social Influences Status (Multiple choice)Does the behavior occur more frequently when social interaction is withheld or presented?
- Part II: Social Reinforcement Status (Multiple choice)Does the behavior help the client escape or avoid undesirable tasks or demands?
- Part III: Nonsocial Reinforcement Status (Multiple choice)Does the behavior appear to serve an automatic sensory or self-stimulatory function?
- Additional Information (Paragraph)Please share any other context, historical notes, or observations that may assist with the evaluation.
FAQ
How do I share this form with caregivers or informants?
Once your template is generated in Google Forms, simply click the Send button to copy the link and email or text it directly to informants for completion.
Can I customize the screening questions for specific patient age groups?
Yes. Google Forms allows you to fully edit, add, or remove any questions so you can tailor the assessment for pediatric, adult, or geriatric care.
Where are the screening responses saved?
All submissions are securely stored in your personal Google Drive account and automatically linked to a Google Sheets spreadsheet for easy analysis.
Is this form template free to use?
Yes, Doc2Form provides this template for free so you can instantly set up your assessment workflow in Google Forms.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.