Be the Expert in the Room

1
What is your child’s first name or nickname?* This field is required.
2
How old is {childname}?* This field is required.
2 Years Old
3 Years Old
4 Years Old
5 Years Old
6 Years Old
7 Years Old
8 Years Old
9 Years Old
10 Years Old
11 Years Old
12 Years Old
13 Years Old
14 Years Old
15 Years Old
16 Years Old
17 Years Old
18 Years Old
19 Years Old
20 Years Old
21 Years Old
3
What's {childname}'s Medical Diagnosis?* This field is required.
Autism
ADHD
Both Autism & ADHD
Other
4
What's {childname}'s Medical Diagnosis?* This field is required.
5
How would you rate {childname}’s energy level on most days?* This field is required.
Energy Level
Very Low Energy
Low Energy
Neutral
High Energy
Very High Energy
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Energy Level
Very Low Energy
Low Energy
Neutral
High Energy
Very High Energy
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6
How would you rate {childname}’s coordination when catching, throwing, or kicking a ball ⚽?* This field is required.
Rarely Participates
Emerging
Skillful
HIghly Skilled
Coordination
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Coordination
Rarely Participates
Row 0, Column 0
Emerging
Row 0, Column 1
Skillful
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HIghly Skilled
Row 0, Column 3
7
How patient is {childname} in most situations?* This field is required.
Patience Level
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Patience Level
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8
{childname} could happily spend hours doing…* This field is required.Name an activity or a toy
9
What are {childname}’s top 3 favorite games or toys to play with?* This field is required.
10
What are {childname}’s favorite cartoons or movies 📺?* This field is required.
11
What type of textures does {childname} seem to avoid 😨 and enjoy 😀?Soft vs. Scratchy, Smooth vs. Bumpy, Wet vs. Dry, Sticky vs. Slippery, Rough vs. Soft, Crunchy vs. Chewy
Avoid 😨
Enjoy 😀
12
How does {childname} respond to textures or games they dislike?* This field is required.For example: Do they ask to stop, cry, or throw things?
13
What are the top 3 things others might do that tend to upset{childname} quickly😤?* This field is required.
14
What are 3 activities you wish were easier for {childname} to do?* This field is required.
Activity #1
Activity #2
Activity #3
15
When shopping or out in the community, how does {childname} usually spend most of the time? 🛍️* This field is required.Does your child explore, stay close to you, become overwhelmed, or engage in specific activities.
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16
What is {childname}’s favorite toy, and how does {childname} play with it?* This field is required.
17
In the classroom or a group setting, {childname} often prefers to...* This field is required.
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18
Which senses does {childname} use the most to explore their world every day?* This field is required.Select all that apply
Vision 👁️: Looks closely at toys, lights, or videos, sometimes using the corners of their eyes.
Smell 👃: Inspects toys or food by smelling them first.
Body 🏃‍♂️‍➡️: Moves constantly, always on the go, using their whole body to explore.
Hands 👐: Touches everything to understand and interact with it.
Ears 👂: Loves listening to songs or specific sounds.
Mouth 👄: Explores objects by putting them in their mouth, even things they’re not supposed to.
19
When {childname} gets upset😭, how does {childname} typically respond?* This field is required.Please describe what happens, including any specific behaviors or patterns you’ve noticed.
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Small
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20
How long can {childname} walk without needing a break 🥱?* This field is required.
5–10 minutes
10–20 minutes
20–30 minutes
30–45 minutes
45–60+ minutes
21
If you had to describe {childname}’s typical day in three words, what would they be?* This field is required.
Word #1
Word #2
Word #3
22
Parents or Caregivers Name* This field is required.
First Name
Last Name
23
Email* This field is required.
example@example.com
24
Phone Number* This field is required.
Area Code
Phone Number
Should be Empty: