ASD Parent Questionnaire

Learner’s Name:

Person completing the form:

Referral made by:

Diagnosis:

At which age did you become concerned about your child’s development and why?

Did any of your child’s behaviours concern you? Explain.

Briefly explain the process that led to diagnosis of ASD:

DEVELOPMENTAL HISTORY
SPEECH AND LANGUAGE DEVELOPMENT

 
Did your child babble? YesNo

Speech and language problem first noticed at what age?

How does your child most often communicate (Please tick)

Verbal CommunicationSign Language e.g. MakatonThe Picture Exchange Communication System (PECS)Augmentative Device

BASIC DEVELOPMENTAL INFORMATION
Milestone Ages:

 
Sitting:

Crawling:

Walking:

Potty training:

Which hand does your child use to eat? RightLeft

Draw or write? RightLeft

Throw a ball? RightLeft

What are your child’s interests?

Movies/TV shows-:

Music-:

Books-:

Games-:

Other-:

Does your child have any obsessive interests? (interests that are more intense and more focused)

How does your child make it known that he/she is upset?

What triggers a meltdown? (behaviour outburst)

Is the following behaviour often present during a meltdown?

 
Screaming YesNo
Aggression towards others (biting, hitting, etc.) YesNo
Throwing/Breaking objects YesNo
Self-injury YesNo
Crying YesNo

Other (explain):

Behaviours that we need to be aware of:

 
Hyperactivity (difficulty settling down, impulsive) YesNo
Self-Stimming (repetitive body movements or sounds) YesNo
Non-Compliance (difficulty following instructions/completing tasks) YesNo
Inattention (difficulty with joint tasks or focusing for long periods) YesNo

What strategies can be used to calm your child during a meltdown?

 
Tickles YesNo
Hugs YesNo
Singing YesNo
Deep Pressure YesNo
Clapping YesNo
Back Rubs YesNo

Other (explain):

Is your child a fussy eater? YesNo
If your child is shown a picture of a relative does he/she recognise the person in the picture? YesNo
Does your child ever draw your attention to something happening? (e.g. pointing to a flying bird) YesNo
Does your child seek help when exploring a new object or encountering a challenge? YesNo
Does your child notice if he/she is left alone in a room? YesNo

How does your child get your attention?

How does your child interact with familiar adults?

How does your child interact with unfamiliar adults?

How does your child interact with familiar peers?

How does your child interact with unfamiliar peers?

Sibling Information:
Name: Male/Female: Age: Grade: School: Biological/Step

Educational History
Record of Schools Attended

Please indicate the names of all the schools that your child has attended including Pre-grade and Nursery schools.
 
Name of School: Male/Female: Year: Grade: Grade/Group: Biological/Step

What are your child’s areas of strength?

What are your child’s areas in need of development?

What motivates your child to participate in activities?

What are your goals for your child?

Any additional information that needs to be noted about your child?

Are you willing and able to work at home with your child YesNo
Are you willing to attend parent meetings to discuss your child’s progress YesNo