MindWeal Parent ASD Questionnaire

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Welcome to our exploration of Autism Spectrum Disorder (ASD). Your insights are invaluable in helping us understand your student’s unique journey. This questionnaire delves into how social, communicative, and behavioral differences may present in your student.

Your role? Crucial! You help us gain a clearer perspective of your student’s experiences in the classroom. Together, we can decode these intricacies and support your student’s development with understanding and care.

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Today's Date:* This field is required.

Date

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Child's Name:* This field is required.

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Child's Date of Birth:* This field is required.

Date

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Teacher's Name:* This field is required.

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Understanding Teacher-Student Interaction: How would you describe your level of interaction with this student?* This field is required.

Primary Teacher (Teaches all subjects, interacts with the student for several hours each day)

Core Subject Teacher (Teaches one or more key subjects and interacts with the student multiple times a week)

Elective/Specialty Teacher (Teaches a specific subject, like art, music, or physical education, with limited weekly interaction)

Homeroom Teacher (Oversees the student daily but primarily for administrative tasks and brief check-ins)

Support Staff or Occasional Teacher (Interacts with the student infrequently, such as a substitute teacher or a counselor)

Other

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1. Does your student find it difficult to engage in casual, back-and-forth small talk during social interactions?* This field is required.

Yes

No

Not quite sure

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2. In social situations, does your student sometimes say things or ask questions that might seem a bit out of place or unexpected?* This field is required.

Yes

No

Not certain

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3. Does your student tend to take words literally in conversation, missing the implied or "between the lines" meanings?* This field is required.

Yes

No

Not quite sure

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4. Does your student actively share things that excite them, like a new toy or a favorite game?* This field is required.

Yes

No

Not quite sure

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5. Does your student willingly share their possessions, like toys or food, with you or others?* This field is required.

Yes

No

Not quite sure

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6. Does your student show or communicate feelings of happiness or excitement with you or others?* This field is required.

Yes

No

Not quite sure

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7. Does your student attempt to offer comfort or help when they see someone feeling unwell or distressed?* This field is required.

Yes

No

Not quite sure

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8. Have you observed your student changing their behavior to fit different social settings, like being reserved around strangers or in places like church?* This field is required.

Yes

No

Not quite sure

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9. Does your student struggle to make friends, not out of nervousness, but due to a lack of interest or difficulty understanding how to connect with others?* This field is required.

Yes

No

Not sure

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10. Does your student make eye contact during conversations?* This field is required.

Yes

No

Not quite sure

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11. Sharing glances can create a silent dialogue that deepens bonds during shared activities. Does your student often look to your face for reactions while you're engaged in an activity together?* This field is required.

Yes

No

Not quite sure

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12. In social settings or when meeting new people, does your student use a smile to greet others?* This field is required.

Yes

No

Not quite sure

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13. How does your student usually respond when someone smiles at them during social interactions?* This field is required.

Returns the smile

Rarely or never smiles back

I am uncertain of their usual response

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14. Does your student regularly use common non-verbal, like waving to say goodbye or putting a finger to our lips for silence, in their interactions?* This field is required.

Yes, they use gestures regularly

No, they seldom use gestures

I am not sure

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15. Does your student show a wide range of facial expressions?* This field is required.

Yes, they have a diverse range of expressions

No, their expressions are more subtle or less varied

I'm not sure or it's hard to tell

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16. Do your student’s facial expressions usually reflect their emotions or the context of what they’re communicating?* This field is required.

Yes

No

Not quite sure

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17. Have you noticed your student exhibiting body language that seems unusual or awkward during interactions with others?* This field is required.

Yes

No

Not quite sure

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18. Does your student find it difficult to grasp the body language and facial expressions of others?* This field is required.

Yes

No

Not quite sure

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19. Kids with ASD may not naturally understand personal space and stand too close (in contrast to kids with ADHD who might invade space due to their energy). Does your student understand the concept of personal space, like not standing too close to others?* This field is required.

Yes

No

Not quite sure

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20. Children with ASD might exhibit repetitive behaviors that are quite distinct. Unlike the spontaneous, energetic movements seen in hyperactivity, these can be patterned and persistent, often taking the form of hand flapping or twisting actions near the face. Have you noticed your student engaging in any repetitive behaviors or movements that seem to have a pattern or routine to them?* This field is required.

Yes

No

Not quite sure

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21. Does your student often use unique or unconventional phrases in their speech?* This field is required.

Yes

No

Not quite sure

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22. While it's normal for children to echo favorite catchphrases, kids with ASD may repeat phrases or sentences more frequently and repetitively. Does your student often repeat the same phrases or sentences?* This field is required.

Yes

No

Not quite sure

Other

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23. While all kids might repeat words or phrases, children with ASD may show echolalia, repeating what they've heard right away or later. Does your student often echo words or phrases shortly after hearing them or at a later time?* This field is required.

Yes

No

Not quite sure

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24. Each child has their own unique way of speaking, which adds to their individuality. Some speech patterns may suggest ASD. Please check ALL that apply to your student's speech:

Uses a unique tone of voice, like sounding robotic or lecture-like

Doesn't realize when speaking too loudly

Speaks so slowly, quickly, or unevenly that it's challenging to understand.

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25. Children can be creative with language, sometimes making up their own words. This can be part of their individuality or a sign of ASD. Does your student often use words that seem made-up or invented by them?* This field is required.

Yes

No

Not quite sure

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26. Creative descriptions can reflect a child's inventive mind, but in the context of ASD, they may indicate different ways of interpreting the world. Does your student often describe everyday objects or events in an unusual or indirect ways, like calling steam "hot rain"?* This field is required.

Yes

No

Not quite sure

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27. Does your student frequently mix up pronouns, such as using "you" instead of "I" or saying "he" or "she" when referring to themselves?* This field is required.

Yes

No

Not quite sure

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28. Children with ASD can be upset by even small changes in their environment. Does your student gets upset by minor changes in familiar surroundings, like moving items in the classroom?* This field is required.

Yes

No

Not quite sure

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29. Children with ASD may struggle with small changes to their routines or surroundings. Does your student gets distressed by how their belongings are arranged or slight changes in their daily routine, like switching from long to short sleeves?* This field is required.

Yes

No

Not quite sure

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30. Many children with ASD show a keen interest in order and symmetry, finding comfort in predictable patterns and arrangements. Does your student display any of the following behaviors that suggest a preference for symmetry or specific order? Select ALL that resonate with your student’s behavior:

Always lines up toys in a particular order

Likes to arrange objects symmetrically or in a special sequence

Seems really drawn to patterns that are symmetrical

None of the above

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31. Does your student find it tough to switch between tasks, often becoming really absorbed in completing one thing before moving on to the next? (Remember, this question doesn't cover situations where most children might choose a fun activity over a less enjoyable one, such as picking playtime over chores).* This field is required.

Yes

No

Not quite sure

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32. Has your student ever seemed compelled to do things in a specific order or way? Like they have a set 'routine' or 'ritual' they feel they must stick to?* This field is required.

Yes

No

Not quite sure

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33. Children on the autism spectrum often exhibit remarkably deep and focused interests that may seem too intense. Does your student have any hobbies or interests that stand out due to their unusually intense focus?* This field is required.

Yes

No

Not quite sure

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34. Children with ASD may focus intensely on specific interests that go beyond typical childhood preferences. Does your student have peculiar or unusual interests, like a strong fascination with lights, street signs, toilets, or vacuum cleaners?* This field is required.

Yes

No

Not sure

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35. Children with ASD may become deeply attached to certain items, which give them comfort or a sense of security. These attachments can extend beyond typical objects like a teddy bear or blanket. Is your student strongly attached to an item they often carry, whether it's a common object like a blanket or something unusual like a pipe or a stone?* This field is required.

Yes

No

Not sure

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36. Does your student display heightened sensitivity to noise? In other words, do they react strongly or seem bothered by loud sounds more than other kids?* This field is required.

Yes

No

Not sure

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37. Does your student sometimes become noticeably upset or irritated by specific sounds, like someone coughing or a baby crying?* This field is required.

Yes

No

Not sure

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38. Does your student react strongly to certain aspects of food, like taste, smell, texture, or appearance, and/or engage in rituals related to these aspects?* This field is required.

Yes

No

Not sure

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39. Children on the autism spectrum often exhibit distinct preferences or fascinations due to their heightened sensory awareness. We're exploring the various ways your student may experience the world around them. Select ALL the statements listed below that apply to your student:

Shows an unusual interest in the appearance, feel, sound, taste, or smell of objects or people. For instance, they might sniff toys, objects or people in a way that seems out of the ordinary.

Appears overly concerned with the feel or texture of items they come into contact with.

Displays a noticeable fascination with observing lights or watching objects as they spin.

None of the above

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Total score:

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Current Score Interpretation (Beta Version)

Score	Interpretation
0 - 20	ASD not likely
21 - 50	ASD somewhat likely
51 - 126	ASD likely
127 - 162	ASD very likely