Forms for Behavioral Intervention and Support

About these Forms

One of the forms in Guidance for Planning Behavior Intervention for Children and Young Adults who are Deafblind or have Visual and Multiple Impairments
One of the forms in Guidance for Planning Behavior Intervention for Children and Young Adults who are Deafblind or have Visual and Multiple Impairments.

The forms included in this document are designed to capture typical data collected by a team along with specialized information that is critical for a student who is deafblind or has visual and multiple impairments. We encourage all teams to consider all the questions that are included as they take into consideration the specialized needs of the child who is deafblind or has visual and multiple impairments. (Note: you may want to have various members take the lead on responding to a particular step. For example, the school nurse may have much of the information that is needed in the section on medical issues. An intervener may be able to answer some of questions better than the teacher of students who are visually impaired. If there is a teacher of students who are deafblind, they may want to take the lead on gathering this information.)

Teams should be proactive in supporting the social and emotional development of these children who are deafblind or has visual and multiple impairments.  They do this by providing quality intervention and instruction developed for the specific unique strengths, preferences, and challenges of the child. We consider these to be Tier 2 level interventions and supports.

However, sometimes, additional responsive intervention is needed after implementing Tier 2 level interventions and supports. This occurs when the child continues to show signs or escalates to extreme distress and exhibits behaviors that are self-injurious, highly disruptive or can hurt others. At this point, the educational team typically develops a formal Behavior Intervention Plan (BIP). Most school districts have standard processes and forms they use for this purpose.

For the Tier 3 Student – A note to the assessor

During creation of a Behavior Intervention Plan, a Functional Behavior Assessment (FBA) will be completed.  Traditionally, the functions of behaviors identified fall into a few common motivations, such as gaining attention or tangible items, or rejecting activities and situations.  Some formats lead assessors to select motivations such as control, escape, revenge, attention seeking, or sensory stimulation.

However, these frequently identified functions do not include recurrent explanations of distress leading to behaviors that are not as purposeful in the same way.  Many students who blind or deafblind with additional disabilities may respond to distress related to sensory, emotional or physical complications, past experiences of perceived adversity; difficulty being understood when expressing concerns, or other factors unrelated to the motivations found on FBA checklists.

The underlying factors leading to behavioral episodes for students who are deafblind or visually impaired with additional disabilities often might include:


    • Distress from being repeatedly misunderstood when expressing needs, choices, or concerns.
    • Confusion/anxiety from receiving incomplete, distorted or fragmented information.
    • Panic (fight, flight, freeze) response to something perceived as threatening.
    • Situations or circumstances that remind the student of a past trauma or adverse experience.
    • Managing physical difficulties such as balance problems, instability, glare, or noise.
    • Masking other physical or emotional pain.
    • Feelings of isolation or loneliness.
    • Regret, grief, or loss.

Steps to Planning Behavioral Interventions and Supports

Below are links to completed samples of specific forms you may want to use to organize information with your team. You may not choose to use all of these forms as a part of your documentation process of the team’s efforts, but we encourage you to discuss all of these aspects of providing interventions and supports to the child who is deafblind. You will find all of these forms to download and print out for your use on pages 24-57 of the document.

Step 1 – Clarify Information about Concerns

Step 2 – Gather Additional Information

Step 3 – Gather Basic Health Considerations and Other Issues

Step 4 – Review the Current Program

Step 5 – List of Intervention and Supports – Tier 2

Step 6 – Taking Data on Observable Behaviors

Step 7 – Tier 3 Responsive Intervention and Supports

Step 8 – List of Intervention and Supports – Tier 3

Step 9 – Behavior Intervention Plan

Step 10 – Take Data on Observable Behaviors