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Behaviors of Concern
Aggression Towards Others
Does your loved one engage in any of the following specific behaviors of concern; Check all that apply
Bites
Hits Others
Kicks Others
Throws Objects at Others
Scratches Others
Spits at Others
Verbal Aggression (may include threats of harm, bullying. yelling, screaming not due to discomfort or pain).
Destruction of Property or Surroundings
Does your loved one engage in any of the following specific behaviors of concern; Check all that
Breaks or Damages Items
Swiping items off surfaces or walls
Throw Objects
Tipping over/moving furniture
Inattentiveness/ Hyperactivity/ Hypo-activity
Easily distracted, requires prompts to complete tasks
Requires constant redirection to stay on tasks
Inappropriate Sexual Behavior
Disrobing
Exposing Self
Grooming/ Predatory Behavior
Groping/ Touching
OthersPublic
Masturbation Solicitation/ Exploitation
Oppositional Defiant Behaviors
Disregard for Authority
Physical Resistance
Task Refusal
Repetitive Restrictive Behaviors
Repetitive Physical (i.e., hand flapping, spinning, rocking, etc.)
Repetitive Verbal/ Vocal (i.e., humming, scripting, perseveration of preferred topics, repetitive speech, etc.)
Safety Concerns
Elopement/ Wandering (i.e., leaving designated area without permission)
Unable to identify age-appropriate personal information in an emergency situation
Unaware of Stranger Danger
Unaware of surroundings
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I declare that the info I’ve provided is accurate and complete.*