Autism Services 2

Learner's Name

First NameLast Name

Location of Interest ?

Primary diagnosis

Diagnosing Provider

Date of Initial Diagnosis

Secondary Diagnosis

Physician or provider who diagnosed

Age when diagnosed

Primary Care Physician

Physician Office Phone

Please enter a valid phone number.Format: (000) 000-0000.

Parent or Guardian 1

First NameLast Name

Primary Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address: (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County of Residence

Marital Status

Parent or Guardian 2

First NameLast Name

Primary Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address: (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County of Residence: (if different than above)

With whom does the learner legally reside with ?

First NameLast Name

Emergency Contact 1

Emergency Contact 1 Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact 2

Emergency Contact 2 Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

YesNo

If yes, please list and explain

YesNo

If yes, please list and explain

Are any family members known to have the following medical conditions ?

Rows	Y or N	Parents or Siblings	Grandparents, aunts, uncles or cousins
Autism Spectrum Disorder
Mental Retardation/Intellectual Disability
Speech or Language Disorder
Severe Communication Problems
Mental Health Problems
Emotional Health Problems Alcohol/Substance Abuse or Misuse
Severe Behavioral Problems
Severe Emotional Disturbance
Victim of Physical, Mental, Emotional or Sexual Abuse
Perpetrator of Physical, Mental, Emotional or Sexual Abuse
Suicidal/Danger to Self
Homicidal/Danger to Others
PTSD or history of significant traumatic events
Eating or Feeding difficulties
Depression or Other Mood Disorders
Obsessive or Compulsive behaviors
Extremely narrow or limited interests
Antisocial Behaviors

For any ‘Yes’, please specify details

Please list the names and ages of any other individuals that live in the home

YesNo

List any allergies and adverse reactions that occur, or list NKA if no known allergies.:

Please tell us why you are seeking treatment for your learner:

YesNo

Please list any prescription medications your learner is currently taking.

Rows	Name	Dosage	Date of Initial Prescription
Prescription
Prescription
Prescription
Prescription

Additional Medications

Does your learner have a history of any of the following?

Rows	Y or N ?	Details
Staring Spells
Seizures
Head Trauma
Speech Problems
Tics or Repeated Movements
Rapid Weight Loss
Rapid Weight Gain
Trouble with Appetite
Unexplained Fevers
Vision Problems
Hearing Problems
Lung Problems
Stomach or Bowel Problems
Diarrhea or Constipation
Urinary Tract Infections
Kidney Problems
Broken Bones or Joint Problems
Skin Problems
Endocrine Problems
Anemia
Prenatal/Perinatal events
Allergies to medications, food, etc
Problems Swallowing
Infectious Disease
Substance use/Abuse
Genetic Abnormalities

Please share details of any relevant medical tests or evaluations completed

Rows	Date	Provider's Name	Facility Name	Results
Psychology or Neuro-Psychology evaluation
Brain wave test, EEG, electroencephalogram
CT or MRI of the head
Blood Chromosome Test
Generic Testing
Former Evaluations for Autism

YesNo

School Name

What is your learner's current grade in school?

Please describe any special learning accommodations your child receives in school ?

What days and times does your child attend school ?

Please describe the teaching goals & objective for your child's current school year or please provide a copy of the current IEP.

Upload IEP if available.

How does your child feel about their current educational program ?

How do you feel about your child’s current educational program ?

Has your child ever been suspended or expelled from school or transportation services ?

Upload File

Has your learner received any rehabilitative therapies, now or in the past ?

Rows	Start Date ?	End Date	Clinician	Facility
Speech Therapy
Occupational Therapy
Physical Therapy
ABA Therapy

YesNo

Please describe your learner's response to treatment and any notable progress or challenges

If so, please state the start date, supervising clinician, company name, phone number or email address

If so, please describe the past or current program goals and objectives and how specific goals are taught

Please list any other community resources that support your family and/or your learner

Please provide the following information regarding your learner’s developmental milestones. If not yet achieved, list N/A.

Rows	List age; any additional info
By what age did your learner sit alone quietly for 3-5 minutes?
By what age did your learner walk independently?
By what age did your learner make verbal requests?
By what age did your learner engage in functional play with toys?
By what age did your learner engage in pretend play?
By what age was your learner able to remain dry during waking hours?
By what age was your learner able to complete toileting routines independently?
By what age did your learner use meaningful sentences with 5+ words?

Are there any other concerns you have that you have not mentioned above?

Please describe any unusual circumstances that took place during your learner’s pregnancy and delivery.

Please describe any notable experiences your learner had with meeting developmental milestones.

Please describe any notable challenges your learner experienced with toilet training. Provide details about the age at which your learner successfully completed daytime and nighttime toilet training.

Please detail the age at which your learner began childcare and any notable circumstances.

Please detail the age at which your learner began schooling and any notable circumstances.

Please detail your initial concerns regarding your learner’s development, and the age at which that occurred.

Please detail your learner’s current communication skills and any concerns that you have.

In 1-2 sentences, how would you describe your child (strengths, personality, interests, etc.)?

On a scale of 0 to 5, please rate the following as it pertains to your learner:

Rows	Rating
Highly responsible
Tries hard to do work
Makes good use of time
Relates well to others
Completes tasks
Cooperative
Daydreams too much
A loner
Prefers adult company
Uncooperative with children
Uncooperative with adults
Denies mistakes, blames others
Sensitive to others’ needs
Easily frustrated
Fails to finish things
Always "up and on the go"
Poor control of anger
Talkative or silent
Acts before thinks
Demands immediate attention

Who shares the responsibility of disciplining your learner at home?

Rows	Name	Relationship	Shared percentage of discipline
Individual 1
Individual 2
Individual 3
Individual 4

Please indicate which disciplinary techniques are used at home:

Rows	Yes or No
Isolation
Time-out
Spanking
Withholding privileges
Stern talking
Reasoning/Explaining
Grounding

Other:

YesNo

If yes, please describe what this looks like and your typical response. If no, put N/A.

YesNo

If yes, please describe what this looks like and your typical response. If no, put N/A.

YesNo

If yes, please describe what this looks like and your typical response. If no, put N/A.Type a question

Please describe any other safety concerns that you have for your learner.

Please list any other problem behaviors your learner exhibits

Please explain how these problem behaviors interfere with daily activities

Thinking of the behaviors you described above, please share any relevant information about why you think they occur.

Do these problem behaviors occur during specific times (time of day, week, month, year, etc.) ?Type a question

If you do not have details to share, put "unsure"

Do these problem behaviors occur in specific settings (locations, activities, events, etc.) ?

If you do not have details to share, put "unsure"

Is your learner looking for a specific response to these behaviors (access to something, removal from somewhere, attention from someone, etc.) ?

If you do not have details to share, put "unsure"

How often do the problem behaviors occur?

If you do not have details to share, put "unsure"

What does a ‘crisis’ look like for your learner ?*

How often does a crisis experience occur ?*

What typically happens immediately before and immediatelyafter a crisis experience occurs?*

What strategies do you use to de-escalate and reduce the occurrence of crisis situations for your learner ?*

What results have you noticed in your learner’s response to the strategies you described ?*

Describe your learner’s ideal behaviors that would occur instead of the stated problem behaviors in a crisis situation?*

Autism Services 2

Therapy History

Functional Assessment Interview of Possible Functions of Problem Behavior