Positive Behaviour Support Plan

Student: NAME D.O.B: DATE

Grade: # Student PEN: PEN #
School: SCHOOL NAME Ministry code: LETTER

Delete this paragraph and replace it with your Interpretive Summary. Include a summary of information from
the Staff Interview that helps the reader to understand 1) who the child is, and 2) why the goals were chosen as
the goals for service. Keep this section brief and to the point.

Information can then be summarized from each of the sections (listed below), if there is a direct relation to the
student’s goals identified. Again, only include information pertinent to what needs to be addressed; other
information may be left off this plan.

Key Strengths:
Provide the area of strengths the school has reported for this student.

The School Team’s Concerns:

Medical

Environmental Characteristics & Accommodations

Sensory Regulation

Communication & Assistive Technology

Social

Life Skills

Safety

Academic

Behavior, Emotional Understanding & Regulation

School Vision:
Provide a brief synopsis of the information the school has provided regarding their vison for the student.
GOAL AREAS AND INDIVIDUAL SERVICE PLANS
The following information summarizes the goals that have been identified by the family or other caregivers, assessment results on these goals, and strategies that
may be helpful in achieving the goals.

Summary Statements
Targeted Goal Area 1:

Competing Behaviour Pathways Diagram (CPD):

Desired Behaviour Maintaining Consequence

Events that occur at some Tangible
time preceding the PB; does Attention
not “trigger” the behavior but Escape
“sets the stage” for/ increases
Automatic
likelihood of PB.

Setting Event Antecedent Problem Behaviour Maintaining Consequence/

Function

Alternative Replacement
Behaviour
 Positive Behavior Support Plan
☒ Checked box indicates strategy has been implemented

Setting Event Preventive Teaching Consequence

Strategies Strategies Strategies Strategies
☐ [strategy] check box if ☐ [strategy] ☐ [strategy] ☐ [strategy]
implemented Date of Last Change: Date of Last Change: Date of Last Change:
Date of Last Change: ☐ [strategy] ☐ [strategy] ☐ [strategy]
☐ [strategy] if not implemented at Type out text first then insert check Date of Last Change: Date of Last Change:
discharge, indicate reason following box by selecting “developer” tab.
each strategy listed: Not Date of Last Change:
implemented due to time constraint
Date of Last Change:

Note: (delete from report): If school staff a require more detailed description of strategies, please use an Implementation Checklist and provide as a separate
document.

Mastery Criteria:
[Indicate the outcome or criteria that will be used to determine that this goal has been completed.]
E.g., John will complete his morning routine independently across 5 consecutive days
Frequency of Intervention: [How often the plan should be carried out]
Data:
Measure Used: Person Responsible for Data Collection:
a) [List Measure.] [Name]
 Goals Baseline Data Interim Data Discharge Data
Desired Behaviors: # of # of # of
occurrences/day/wk occurrences/day/wk occurrences/day/wk

Undesired Behaviors:

Date of Next Review: [Date of next formal review of plan]; “NA” if Discharge Report]
Extenuating and Influencing factors:
[Any extenuating or influencing factors that affect the outcomes of this plan.]
Additional Information:
[Any additional information on using the strategies in this plan.]