Spectrum Assessment Form

Client Name:

First NameLast Name

Date:

Date

Client Age:

Email:

example@example.com

Status:

Number of Sessions:

Answers to these questions are not required for medication usage; however, accurate responses may help us more effectively personally tailor your training program. No information provided on this questionnaire will be shared outside the A Chance To Grow staff without your expressed permission.

Current Medications:

Rows	Medication/Dosage	Dates of Use	Symptoms of over/under-dose
1
2
3
4
5

Rate your child's everyday stress level on a scale of 1-10:

What would optimum performance look like to you?

Is your child experiencing any symptoms you would like to track?

Does your child currently have a medical/psychiatric diagnosis or are there any past diagnoses you think we should be aware of?

Please rate the following behaviors on a scale of 1-10. Please use 1 as being not a problem, and 10 being the most escalated behavior.

1 = Minor problem
2, 3, 4 = Problem - But I work around it
5 = Definitely a problem - Can't ignore but can live with it
6, 7, 8 = Big problem - Blocks who I want to be
9, 10 = Huge problem - Don't know what to do / overwhelmed / panic attacks

Behavior:

Rows	1	2	3	4	5	6	7	8	9	10
Understands/follows directions
Pays attention in class
Sits still in his/her seat
Completes assigned work
Organized in his/her work habits
Gets up and walks around the classroom
Shouts out; can't wait to be called on
Cooperates/participates in group activities
Pays attention to activity/task at hand

Language:

Rows	1	2	3	4	5	6	7	8	9	10
Consistently responds to own name
Points to familiar objects when asked
Obeys simple instructions such as "give me your cup"
Follows a sequence of commands (one item, 2-step directions, 3-step directions)
Follows new (novel) directions
Responds appropriately to more than 2 choices
Understands better if instructions are sung rather than spoken
Babbles
Jargons in own "language"
Talks in single words
Talks in complete sentences
Asks questions
Speech is understandable by strangers
Voice has unusual intonation, loudness or pitch
Repeats phrases or questions instead of answering them
Confuses pronouns
Repeats words/phrases over and over
Engages in conversation
Obsessive, repetitive interest in certain subjects
Uses words/phrases in odd combinations

Nonverbal Communication:

Rows	1	2	3	4	5	6	7	8	9	10
Conveys wants & needs with gestures (without speech)
Takes adult by hand for help, leads adult to what s/he wants
Shakes head for "no"
Nods head for "yes"
Has appropriate variety of facial expressions
Understands other person's emotions (happy, sad, angry)

Relating with Other People:

Rows	1	2	3	4	5	6	7	8	9	10
Enjoys cuddling/hugging appropriately, being held
Prefers to be by self
Aloof, distant, "in a world of his/her own"
Clings to people
Stranger anxiety
Parallel play with peers
Plays interactively with other peers (not parallel play)
Has friends same age
Aggressive to adults or children
Behaves well in public
Cooperates in structured activities/learning
Socially appropriate questions or statements with others

Visual Responses:

Rows	1	2	3	4	5	6	7	8	9	10
Avoids looking at people when they talk to him/her
Fascinated with lights and/or shiny objects
Stares vacantly
Focuses on small parts of an object
Gazes at parts of his/her body
Looks at things out of peripheral vision than directly
Likes to watch things spin

Hearing Responses:

Rows	1	2	3	4	5	6	7	8	9	10
Often ignores some sounds
Overly sensitive to certain sounds
Overly fascinated by some sounds

Other Sensory / Motor Responses:

Rows	1	2	3	4	5	6	7	8	9	10
Insensitive to pain/heat/cold
Overreacts to pain
Spins self around
Unusual gait, such as tiptoe walking
Rocks in bed/chair or foot to foot
Jumps when excited/upset
Bites self or others
Head-banging, or other self-injurious behavior
Postures or wiggles hands or fingers in unusual way such as flapping
Explores objects/people through taste or smell
Awkward in fine/gross motor activities
Avoids touching certain textures such as food, clothing, sticky things
Dislikes being touched
Enjoys rough and tumble play

Emotional Responses:

Rows	1	2	3	4	5	6	7	8	9	10
Temper tantrums
Moods change quickly for no apparent reason
Little response to what is happening around him/her
Unaware/unafraid or real dangers, such as traffic, electrical outlets
Responds appropriately to other people's feelings
Has special fears
Gets overly upset by certain things or situations
Not easily calmed
Difficult to manage or discipline

Reactions to Change:

Rows	1	2	3	4	5	6	7	8	9	10
Gets upset when daily routine changes
Arranges objects in unusual ways
Replaces things in exact position, down to smallest detail
Attachments to unusual objects that must accompany him/her everywhere
Will wear only certain clothes, regardless of weather or conditions
Gets upset if objects in house are moved or rearranged
Wants everything to be exact, perfectionist
Difficulty transitioning from one activity to another

Play and Use of Materials / Objects:

Rows	1	2	3	4	5	6	7	8	9	10
Repetitive play with objects for long periods
Little variety in play
Imitates (pat-a-cake, peekaboo, bye-bye or age appropriate imitations)
Plays with toys appropriately
Spins objects or wheels of toys excessively
Engages in imaginative creative play

Special Skills:

Rows	1	2	3	4	5	6	7	8	9	10
Especially good at taking apart/reassembling or manipulating mechanical objects
Outstanding musical skills
Unusually good at putting puzzles together
Does lengthy calculations in his/her head
Extraordinary memory, such as lists, names, details, numerical facts, timetables
Recognizes routes and places with unusual accuracy
Special rituals (comment below)

Special rituals:

Activity Level:

Rows	1	2	3	4	5	6	7	8	9	10
Often overactive
Often under-active, lethargic, difficult to motivate
Short attention span
Easily distracted
Not much interest in things
Easily overwhelmed

Eating Habits:

Rows	1	2	3	4	5	6	7	8	9	10
Picky eater, strong preferences
Refuses foods with specific textures
Unusual food preferences (very cold/hot/spicy)
Sudden changes in preferred food

Sleeping Habits:

Rows	1	2	3	4	5	6	7	8	9	10
Sleeps a lot
Sleeps very little
Difficulty getting to sleep at night
Difficulty staying asleep

Self-Help Skills:

Rows	1	2	3	4	5	6	7	8	9	10
Age appropriate toileting
Age appropriate feeding
Age appropriate grooming
Age appropriate dressing

Does your child experience seizures?

If yes, please explain: