Behavior Management Survey

Parent's Name: ____________________ Date: _________

 

Child's Name: ____________________ Date of Birth: ________ Age: ____

 

1.  Which of the following skills does your child need help with?  (check all that apply)

a.  Social Skills:

___  increasing eye contact

___  playing near other children

___  playing with other children

___  sharing/turn-taking

___  waiting

___  remaining calm in groups

___  other:

b.  Communication Skills:

___  following simple directions

___  letting you know when he/she wants something  (e.g. food/toy)

___  letting you know when he/she wants you to do something (e.g. play)

___  letting you know when he/she doesn't want something

___  letting you know when he/she wants your attention

___  letting you know when he/she is enjoying something

___  other:

c.  Flexible Behavior:

___  tolerating changes in routines

___  trying new things

___  tolerating changes in activities

___  playing with toys better

___  reducing self-stimulatory behavior

___ other:

2.  Which of the following behaviors are a concern to you at the present time? (check all that apply)

___  tantrums

___  screaming/crying

___  hurting others

___  destroying objects

___  throwing objects

___  wandering off

___  using his/her body in unusual ways 

___  not responding to "no"

___  conflicts with siblings

___  tuning you out

___  taking toys/objects from other children

___ other:

3.  Why do you think your child behaves in this way?

4.  Which of the following statements best describes the impact of your child's behavior on your family:

___  My child's behavior does not interfere with our family's daily routine.

___  My child's behavior interferes somewhat with our family's daily routine.

___  My child's behavior interferes significantly with our family's daily routine.

5.  Which of the following strategies have you tried at home to manage your child's behavior?

___  praising good behavior

___  providing special rewards for good behavior

___  making events predictable for your child

___  ignoring bad behavior

___  scolding your child for bad behavior

___  time-out after bad behavior

___  restricting privileges after bad behavior

___  physical punishment (e.g., spanking)

___  providing visual cues to aid understanding

Other strategies employed:

 

6.  How effective were these techniques in changing the behaviors your were concerned about?

 

7.  What would you like to gain most from a workshop on behavior management?