Cognitive Disability Strategy

COGNITIVE DISABILITY STRATEGY

Southeast Region REQUEST FOR BEHAVIOURAL SUPPORT/CONSULTATION

FORM B

Referral Information
Name of Person with Challenging Behaviour: / Age:
Date of Request: / Person Making Request / Case Lead:
Contact Information:

A. DESCRIBE THE BEHAVIOUR(S)

1. What are the behaviours of concern? For each, define how it is performed; how often it occurs per day, week, month; how long it lasts when it occurs; and the intensity on which it occurs (low, medium, high).

Behaviour / How is it performed? / How often? / How long? / Intensity?
e.g. / Wanders / Leaves designated areas without permission / 2-4x/day / 30 seconds – 2 minutes / Medium
1.
2.
3.
4.
5.
6.

2. Which, if any, of the behaviour(s) described above occur together (e.g., occur at the same time; occur in a predictable “chain”; occur in response to the same situation)? If so, please explain.

3. Are there early behaviours (precursors) that predict that the unwanted behaviour(s) will occur? If so, please list.

B. MEDICAL/PHYSIOLOGICAL FACTORS

1. What is the current health statusof the applicant? Is the applicant considered to be in good/poor health?

2. Have there been any recent changes in health of the applicant? If so, please explain.

3. Is the applicant currently on any medication? If so, please list.

4. Has there been any recent additions or change to medications? If yes, please explain.

5. What medical complications (if any) does the applicant experience that may affect his/her behaviour (e.g., asthma, allergies, rashes, sinus infections, seizures, etc)?

6. Please state the diagnosis (if any) of the applicant.

7. Describe the sleep cycle of the applicant (e.g., what time he/she goes to sleep and wakes; does he/she wake at night; having difficulty falling asleep; has/does not have a consistent routine, etc)

8. Describe the eating routine and diet of the applicant (e.g., eats well, picky eater, eats too much or not enough; etc)

9. Briefly list the applicant’s typical daily schedule of activities and how well he/she does within each activity.

Weekday (Monday – Friday) Schedule

Time / Activity / Applicant’s Response / Time / Activity / Applicant’s Response
7am / 3pm
7:30am / 3:30pm
8am / 4pm
8:30am / 4:30pm
9am / 5pm
9:30am / 5:30pm
10am / 6pm
10:30am / 6:30pm
11am / 7pm
11:30am / 7:30pm
12pm / 8pm
12:30pm / 8:30pm
1pm / 9pm
1:30pm / 9:30pm
2pm / 10pm
2:30pm / 10:30pm

Weekend (Saturday and Sunday) Schedule

10. Describe the extent to which you believe activities that occur during the day are predicable for the applicant. To what extent does the applicant know what he/she will be doing and what will occur during the day? How does he/she know this?

11. What choices does the applicant get to make each day (e.g., food, activities, etc)?

C. DEFINE EVENTS AND SITUATIONS THAT MAY TRIGGER BEHAVIOUR(S)

1. Time of Day: When are the behaviours most and least likely to happen?

Most Likely / Least Likely

2. Settings:Where are the behaviours most and least likely to happen?

Most Likely / Least Likely

3. Social Control: With whom are the behaviours most and least likely to happen?

Most Likely / Least Likely

4. Activity:What activities are most and least likely to produce the behaviours?

Most Likely / Least Likely

5. Are there particular situations, events, etc., that are not listed above that “set off” the behaviours that cause concern (particular demands, interruptions, transitions, delays, being ignored, etc)? If so, please list.

6. What one thing could you do/say that would most likely make the challenging behaviour occur?

7. What one thing could you do to make sure the challenging behaviour did not occur?

D. PREVIOUS AND CURRENT TREATMENT HISTORY

1. What previous and/or current behavioural intervention programs or strategies have been used as an attempt to manage the problems?

What has been the outcome of such interventions?

2. What behavioural involvement is occurring or has occurred, if any, with other existing service systems (e.g., Mental Health, Education, Community Living Service Delivery, Wascana Rehabilitation Centre, etc)?

What has the outcome of this involvement been?

E. DESCRIBE THE APPLICANT’S STRENGTHS AND LIMITATIONS

1. What are the applicant’s strengths?

2. What are the applicant’s likes/desires?

3. What are the applicant’s limitations?

4. What are the applicant’s dislikes?

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