Functional Behavior Assessment & Behavior Intervention Plan & Informed Consent and Consent to Release Records

Thank you for your interest in services through Pencil & Pathways. Please review the information below. Your signature is required to authorize the provision of services and to confirm your understanding of the evaluation process.

Explanation of Services

Licensed Specialists in School Psychology (LSSPs) provide school-based psychological services to help students succeed academically, behaviorally, and socially. LSSPs work collaboratively with families and school staff to understand factors contributing to student difficulties and to support individualized solutions. All professional staff are credentialed by the Texas State Board of Examiners of Psychologists (TSBEP).

Reason for Referral

The student is being referred by school personnel and/or a parent/guardian due to concerns about behavior that may be interfering with academic or social functioning. A Functional Behavior Assessment (FBA) is being requested to understand the underlying purpose or “function” of these behaviors.

Nature and Purpose of Proposed Services

A Functional Behavior Assessment (FBA) gathers information to better understand the context and function of a student’s challenging behaviors. The process may include:

  • Structured interviews with parents, teachers, and support staff

  • Direct classroom observations

  • Behavior rating scales or questionnaires

  • Review of educational and behavioral records

  • Interview with the student, if appropriate

Following the FBA, a Behavior Intervention Plan (BIP) may be developed. This document includes proactive strategies, skill-building supports, and specific interventions tailored to the student’s unique needs. The goal is to improve behavior and support positive outcomes at school (and at home, when relevant).

Goals of Service

  • Identify patterns and triggers related to the student’s behavior

  • Determine the likely function(s) of the behavior

  • Develop strategies to teach replacement behaviors

  • Collaborate with school teams and families to support consistent implementation

Confidentiality

All services are provided in accordance with professional standards and legal requirements to safeguard confidentiality. Clients are informed of the limits of confidentiality before services begin, as required by TSBEP Rule §465.11.

Confidential information may only be released with written consent, except in the following situations:

  • If there is suspected abuse or neglect

  • If there is a risk of imminent harm to self or others

  • In response to a court order or other legal authority

  • When consulting with other professionals for treatment purposes (without identifying information)

Reports and documentation will include only information relevant to the referral. When records contain information about more than one individual, identifying details of others will be removed unless a separate consent is provided.

Reference: TSBEP Rule §465.12 – Privacy and Confidentiality

Maintenance and Retention of Records

Records are stored securely and retained in accordance with TSBEP Rule §465.22 and relevant laws:

  • Records will be maintained for a minimum of 7 years after services end, or 3 years after the student reaches the age of 18, whichever is longer.

  • All documentation will be stored in a manner that ensures timely retrieval and protects against unauthorized access.

  • In the event that services are terminated or the provider is no longer available, arrangements will be made to transfer records to another qualified professional or custodian in accordance with law.

Consent to Proceed

Your consent is required to begin services. If there are significant changes in the nature, scope, or purpose of the services, a new informed consent will be requested.

Acknowledgment & Signature
I have read and understand the information provided above. I consent for my child to participate in a Functional Behavior Assessment and, if appropriate, the development of a Behavior Intervention Plan. I understand the purpose, procedures, and limitations of confidentiality associated with these services.