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Thank you for contacting the Severe Behavior Disorders Research Clinic!
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We work with individuals of all ages and any diagnosis who engage in problem behavior, such as selfinjurious behavior, aggression, property destruction, noncompliance, stereotypy, elopement, and tantrums.

If you are interested in services for the assessment and treatment of problem behavior, your child will be
added to the waiting list as soon as you send this initial questionnaire (below) to us at
[email protected] or FAX it to 281-283-3510 with attention to Dr. Fritz. (You will not be on the
waiting list until we receive the completed document.)

Our waiting list can be as long as 0-12 months.

We have a variety of research projects in progress at all times and some families might qualify to
participate.
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Our standard cost for services is $50/hour, and we offer a reduced rate for eligible families.

Unfortunately, we are not able to bill insurance companies directly or assist with that process; however, we
can provide you with a letter stating the dates services were provided and cost incurred.
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We are a very small university-based clinic; therefore, all of our correspondence is primarily conducted
through email. Please let us know if you have any questions at [email protected].

We will contact you when your child is next on the waiting list to receive services. In the meantime, if you
need referrals to outside providers, we are happy to send you that information via email.
We look forward to working with you and your family!
Warmest regards,
Jennifer N. Fritz, PhD, BCBA-D
Director, Severe Behavior Disorders Research Clinic
Associate Professor of Behavior Analysis
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Initial Caregiver Questionnaire
Date Completed:
Please return your answers to this questionnaire via email to [email protected] or you may FAX it
to 281-283-3510 with Attention: Dr. Fritz.
Caregiver’s Name:
Child’s Name:
Phone Number:
Child’s DOB:
Email Address:
Child’s Diagnoses:
Child’s Height:
Child’s Weight:
Child’s Vaccination Status: ____ Fully vaccinated
____ Partially vaccinated
____ On Track to Full Vaccination
____ Unvaccinated
Home Address:
Child’s Current Medications (Please list medication, dose, and regimen):
GENERAL QUESTIONS
How did you find out about our clinic?
Did you review the information on our website (https://sites.google.com/site/drjnfritz/)?
If so, was the information provided helpful to you?
COMMUNICATION
How does the child request attention from others? (Please describe what these behaviors look like.)
How does the child request a break from work? (Please describe what these behaviors look like.)
How does the child request access to preferred items and activities? (Please describe what these behaviors
look like.)
PREFERRED ITEMS/ACTIVITIES
What are the child’s favorite toys and activities?
TOYS (examples: dolls, trucks, sensory items – lights, vibration, etc.)
ACTIVITIES (examples: arts & crafts, coloring, watching movies, reading, board games):
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Does your child engage in problem behavior when preferred items are removed or if the child is not
allowed to have something he or she wants?
Is it possible to bring items to the clinic to be used during session?
PROBLEM BEHAVIORS
Please check all problem behaviors that the individual exhibits below.
Self-injurious Behavior
Aggression Against Others
Dangerous Acts
Head banging
Hitting
Eating inedible objects
Head hitting
Kicking
Running away
Body hitting
Biting
Climbing
Self-biting
Scratching
Setting fires
Skin picking
Pinching
Pulling out hair
Head butting
Other Behaviors
Hitting self with object
Throwing objects at others
(Please describe how it looks)
Hair pulling
Disruption / Destruction
Throwing objects
Stereotypy
Overturning furniture
Hand flapping
Breaking items
Body rocking
Kicking surfaces
Hand mouthing
Hitting surfaces
Mouthing objects
Slamming doors
Bizarre/repetitive vocalizations
Screaming
Hair twirling
Spitting
Noncompliance
What is the behavior for which you would like the most immediate assistance?
How frequently does this behavior occur?
Would the behavior occur with a therapist in a clinic setting without you present?
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Does the child exhibit any behaviors that suggest or predict that he/she will probably engage in problem
behavior? If so, what do these behaviors look like?
Please describe the most severe episode of problem behavior. What was happening when the behavior
occurred? What kind of injury or damage was caused by the behavior?
WORK ACTIVITIES
What types of tasks are difficult for the child or tend to occasion problem behavior?
Self-care
Early learning skills
Meal time
Writing skills
Tolerating specific sounds or loud
noises
Social interaction
Math skills
Physical activity
Reading skills
Physical assistance with tasks
Other Tasks
(Please describe how it looks)
If specific tasks or materials evoke problem behavior, is it possible to bring those items to the clinic to be
used during session?
PROBLEMATIC SITUATIONS
Please check all situation(s) in which problem behavior occurs for which you would like the most help
When asked to do something
When no one is around
When he/she is completing a task
When access to an item or activity
is denied
When an item or activity is
removed
When trying to get access to an
item or activity
When no one is giving attention to
him/her
When trying to get a reaction
from others
When having to wait for preferred
item or activity
When trying to leave an undesired
activity, setting, or person
When specific people are present
When people stop interacting with
him/her
When you tell him/her to stop
engaging in the behavior
When you or other are providing
attention to others in their presence
Being in a noisy setting
In a specific setting or location
When moving from one location/area
to another
When there is a change in daily
routine
Other Situations
(Please describe how it looks)
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When having to interact with new
people
During self-help skills
When having to interact with new
items
When he/she is in pain or ill
During meal time
INTERVENTION STRATEGIES
How do you currently handle problem behavior?
How well does each strategy work?
FINAL COMMENTS
Please describe any other issues we should know before the initial consultation below.
(Please return your answers to this questionnaire via email to [email protected] or you may FAX it to
281-283-3510 with Attention: Dr. Fritz.)