If you are human, leave this field blank.ASD Parent QuestionnaireLearner’s NameLearner’s NameName of person completing the formYour nameYour emailReferral made byAt 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 ASDSPEECH AND LANGUAGE DEVELOPMENTDid your child babble?YesNoSpeech and language problem first noticed at what age?At birth1 year old2 years old3 years old4 years oldOlderHow does your child most often communicate (Please tick)Verbal CommunicationSign Language e.g. MakatonThe Picture Exchange Communication System (PECS)Augmentative DeviceMilestone Ages:Sitting0 to 6 months6 to 9 months9 months to 1 year1 year2 years3 yearsCrawling0 to 6 months6 to 9 months9 months to 1 year1 year2 years3 yearsWalking0 to 6 months6 to 9 months9 months to 1 year1 year2 years3 yearsPotty training0 to 6 months6 to 9 months9 months to 1 year1 year2 years3 years plusNot potty trained yet Which hand does your child use to eat?RightLeftDraw or write?RightLeftThrow a ball?RightLeftWhat are your child’s interests? Movies/TV showsMusicBooksGamesOtherDoes 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)ScreamingYesNoAggression towards others (biting, hitting, etc.)YesNoThrowing/Breaking objectsYesNoSelf-injuryYesNoCryingYesNo Other (explain)Hyperactivity (difficulty settling down, impulsive)YesNoSelf-Stimming (repetitive body movements or sounds)YesNoNon-Compliance (difficulty following instructions/completing tasks)YesNoInattention (difficulty with joint tasks or focusing for long periods)YesNoWhat strategies can be used to calm your child during a meltdown?TicklesYesNoHugsYesNoSingingYesNoDeep PressureYesNoClappingYesNoBack RubsYesNo Other (explain)Is your child a fussy eater?YesNoIf your child is shown a picture of a relative does he/she recognise he person in the picture?YesNoDoes your child ever draw your attention to something happening? (e.g. pointing to a flying bird)YesNoDoes your child seek help when exploring a new object or encountering a challenge?YesNoDoes your child notice if he/she is left alone in a room?YesNoIf yes, how will he/she react?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 Sibling 1NameGenderMaleFemaleRelationBiologicalStepAgeName of SchoolGrade Sibling 2NameGenderMaleFemaleRelationBiological 1StepAgeName of SchoolGrade Sibling 3NameGenderMaleFemaleRelationBiologicalStepAgeName of SchoolGrade Sibling 4NameGenderMaleFemaleRelationBiologicalStepAgeName of SchoolGrade Sibling 5NameGenderMaleFemaleRelationBiologicalStepAgeName of SchoolGradeRecord of Schools Attended Please indicate the names of all the schools that your child has attended including Pre-grade and Nursery schools. School 1Name of SchoolYearGrade/Group School 2Name of SchoolYearGrade/Group School 3Name of SchoolYearGrade/Group Please indicate the names of all the schools that your child has attended including Pre-grade and Nursery schools. 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?YesNoAre you willing to attend parent meetings to discuss your child’s progress?YesNoSubmit
