ATEC (Autism Treatment Evaluation Checklist) Form

The Autism Treatment Evaluation Checklist (ATEC) is a one-page mulitple choice form designed to be completed by parents or caretakers. It takes approximately 5 minutes to fill out and covers four areas:

I. Speech/Language Communication (14 questions);
II. Sociability (20 questions);
III. Sensory/ Cognitive Awareness (18 questions); and
IV. Health/Physical/Behavior (25 questions).

Please complete the form and submit it at least 72 hours before each appointment to help our practitioners better understand your childs' capability and monitor progress.

Once we receive the completed ATEC form, your 1st program appointment can be scheduled.

Full Name of child receiving treatment*

First NameLast Name

Date Of Birth*

Date

What is the childs' gender?

MaleFemale

Parent / Legal Guardian Full Name

First NameLast Name

Email Address*

example@example.com

Diagnosis:*

Speech / Language / Communication:*

	No	Sometimes	Yes Definitely
Knows own name
Responds to ‘No’ or ‘Stop’
Can follow some commands
Can use one word at a time (No!, Eat, Water, etc.)
Can use 2 words at a time (Don't want, Go home)
Can use 3 words at a time (Want more water)
Knows 10 or more words
Can use sentences with 4 or more words
Explains what he/she wants
Asks meaningful questions
Speech tends to be meaningful/relevant
Often uses several successive sentences
Carries on fairly good conversation
Has normal ability to communicate for his/her age

Sociability:*

	No	Sometimes	Yes Definitely
In a shell – difficult to reach him/her
Ignores other people
Uncooperative and resistant
Prefers to be left alone
Avoids contact with others
Temper tantrums/ meltdowns
Insensitive to others feelings
Indifferent to being liked
Indifferent if parents leave
Pays attention when addressed
Good eye contact
Shows affection
Greets parents
Imitates others
Likes being held/cuddled
Likes to share/show things
Waves "bye bye"
Compliant
Has friends
Smiles a lot

Sensory / Cognitive Awareness:*

	No	Sometimes	Yes Definitely
Responds to own name
Responds to praise
Looks at people and animals
Looks at pictures (and TV)
Does drawing, colouring, art
Plays with toys appropriately
Appropriate facial expressions
Understands stories on TV
Understands explanations
Aware of environment
Aware of danger
Shows imagination
Initiates activities
Dresses self
Curious, interested
Venturesome - explores
“Tuned in” — Not spacey
Looks where others are looking

Health / Physical / Behavior:*

	No	Sometimes	Yes Definitely
Bed-wetting
Wets pants/nappy
Soils pants/nappy
Diarrhoea
Constipation
Sleep problems
Eats too much/too little
Extremely limited diet
Hyperactive
Lethargic
Hits or injures self
Hits or injures others
Destructive
Sound-sensitive
Anxious/fearful
Unhappy/crying
Seizures
Obsessive speech
Rigid routines
Shouts or screams
Demands sameness
Often agitated
Sensitive to pain
“Hooked” or fixated on certain objects/topics
Repetitive movements (stimming, rocking, etc.)

Speech / Language / Communication total:

Sociability total:

Sensory / Cognitive Awareness total:

Health / Physical / Behavior total:

Grand total:

Do you give permission for us to use this de-identified data.*

YesNo

Signature*

Date

Hour MinutesAM/PM Option