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    Reinforcement Survey Form: Child'S Name: Age

    Uploaded by

    Pamela Perello
    This reinforcement survey form collects information about a child's interests and preferred reinforcers to be used during therapy sessions. It asks caregivers to identify which toys, activities, foods, social interactions, and sensory items the child enjoys and will motivate their behavior. The form also requests details about toys, foods, and activities the child frequently requests to better understand their individual interests.

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    Reinforcement Survey Form: Child'S Name: Age

    Uploaded by

    Pamela Perello
    10 views3 pages
    This reinforcement survey form collects information about a child's interests and preferred reinforcers to be used during therapy sessions. It asks caregivers to identify which toys, activities, foods, social interactions, and sensory items the child enjoys and will motivate their behavior. The form also requests details about toys, foods, and activities the child frequently requests to better understand their individual interests.

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    Original Title

    REINFORCEMENT SURVEY FORM

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    This reinforcement survey form collects information about a child's interests and preferred reinforcers to be used during therapy sessions. It asks caregivers to identify which toys, activities, foods, social interactions, and sensory items the child enjoys and will motivate their behavior. The form also requests details about toys, foods, and activities the child frequently requests to better understand their individual interests.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    10 views3 pages

    Reinforcement Survey Form: Child'S Name: Age

    Uploaded by

    Pamela Perello
    This reinforcement survey form collects information about a child's interests and preferred reinforcers to be used during therapy sessions. It asks caregivers to identify which toys, activities, foods, social interactions, and sensory items the child enjoys and will motivate their behavior. The form also requests details about toys, foods, and activities the child frequently requests to better understand their individual interests.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 3

    Reinforcement Survey Form

    Child’s name: Age:

    Please help us identify the reinforcers we can use for your child during the sessions. This
    will be a factor in your child’s success in each session.

    Please answer the questions and check the box of the reinforcers that will work on your
    child.

    Toys

    Does your child play with toys? _________

    cars others:_________________________
    puzzle _________________________
    dolls _________________________
    blocks _________________________
    legos _________________________
    musical toys _________________________
    play dough _________________________

    Activities

    blowing bubbles computer time


    painting listening to music
    cleaning watching movies
    playing balls cooking
    swinging others:_________________________
    art projects _________________________
    going on walks _________________________

    Tokens

    stickers others:_________________________
    points
    _________________________
    Reinforcement Survey Form

    stars _________________________
    pictures ________________________
    Food

    Is your child allowed to be reinforced by food? ___________

    vegetables milk
    pretzels others:_________________________
    chocolate _________________________
    biscuits _________________________
    juice _________________________
    candies _________________________
    fruits _________________________

    Social

    high fives others:_________________________


    hugs _________________________
    praises _________________________
    smiling _________________________
    pat on head _________________________
    tickles

    Sensory

    deep pressure rubbing soft items


    trampoline rocking chair
    rice bin jump rope
    lifting heavy items others:_________________________
    squeeze balls _________________________
    lotion _________________________
    bean bag chairs _________________________
    Reinforcement Survey Form

    weighted vest/ blanket _________________________


    massage _________________________
    What toy does your child often ask for?
    _________________________________________________________________________________________________________
    _________________________________________________________________________________________________________

    What food does your child often ask for?


    _________________________________________________________________________________________________________
    _________________________________________________________________________________________________________

    What other items/ activities does your child often ask for?
    _________________________________________________________________________________________________________
    _________________________________________________________________________________________________________

    What does your child likes to do at home?


    _________________________________________________________________________________________________________
    _________________________________________________________________________________________________________

    Date: _______________________________
    Interviewed by: ________________________________

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