Intake Form for ASD

PRESENTING CONCERNS

(please select from the following options: ) [E/C, Play Skills, Peer Interaction, Sensory, Rigidity, R/Name, Repetitive Behaviour, Social interaction, Motor Mannerisms, Language Delay, Preoccupations, Visual Exam, Use of Language, or OTHER] 1. Why are you here? What is your hope for this process? 2. Do you have any concerns about this process? Parental Chief Concerns: [list of concerns from the parent]

Early Language Development

YRPSLP Ax Date: [ ] SLP[ ] Rx[ ] Receptive: [ ] Expressive: [ ] Soc Comm[ ] Play[ ] Update: [Updates since last visit ] Parent Report: [what parent reported to the physician about kid's Social Emotional Reciprocity]

PAST MEDICAL HISTORY

Pregnancy: Maternal Age: [ ] Paternal Age: [ ] # of pregnancies [ ] Complications [ ] GA. [ ] BWT Perinatal Concerns [ ] Functional Review: Hospitalizations: [ ] Surgeries/ Procedures: [ ] Meds: [ ] Supplements:[ ] Allergies:[ ] Immunizations:[ ] Specialists:[ ] Investigations:[ ] Diet:[ ] GI:[ ] Sleep:[ ] Seizures/ Tics:[ ] Hearing:[ ] Vision:[ ] Dental:[ ]

FAMILY HISTORY

86. Family members and living situation: [ ] Mother [ ] Father [ ] Consanguinity [ Yes/No ] [ ] Siblings (age, grade, developmental/ medical concerns)

Additional Notes

[Additional Notes]

Chief Complaint

Comprehensive Developmental Assessment Template

CURRENT SERVICES

(Please select from the following options: ) [EIS: ] [SLP: ] [Child Care / School: ] [OT/PT: ] [ABA: ] [Other:]

Informal Observations and ADOS

** Social Emotional Reciprocity Yes[ ] No[ ] ** Child is having difficulty with: [ ] social approach [ ] conversation [ ] sharing interests/ emotions, affect [ ] initiating and responding to social interaction (include response to name) Parent Report [what parent reported to the physician about kids' difficulties] Observations/ ADOS [ ] Childcare/ School Questionnaire: [ ]

PLAY SKILLS

Child is doing: [ ] cause/ effect [ ] simple pretend [ ] sequenced imaginative play Parent Report: [ what parent reported to the physician about kids' play skills] Observations: [ ] Childcare/ School Questionnaire:

Nonverbal Communication

** Nonverbal Communication [ ] yes [ ] no ** Child is having difficulty with: [ ] E/C. [ ] Body Language [ ]Understanding and using gestures & facial expressions (including pointing). [ ] Giving/ Showing. [ ]Hand as Tool Child is using: [ ] informational gestures. [ ] descriptive gestures Parent Report: [what parent reported to the physician about kids' nonverbal communication difficulties] Observations/ ADOS: [ ] Childcare/ School Questionnaire: [ ]

Relationships

**Relationships [ ] yes [ ] no** Child is having difficulty with: [ ] developing, maintaining and understanding relationship [ ] adjusting behavior to suit the social context [ ] sharing imaginative play [ ] making friends, interest in peers Parent Report: [what parent reported to the physician about kids' relationships] Observations/ ADOS: [ ] Childcare/ School Questionnaire: [ ]

Stereotyped or repetitive motor movements, use of objects or speech

**Stereotyped or repetitive motor movements, use of objects or speech (such as motor stereotypes, lining up toys or flipping objects, echolalia and idiosyncratic phrases) [ ] yes [ ] no ** Child is having difficulty with: [ ] motor movements [ ] use of objects [ ] speech Parent Report: [ ] Observations/ ADOS: [ ] Childcare/ School Questionnaire: [ ]

Insistence on sameness, inflexible adherence to routines or ritualized patterns of verbal or nonverbal behavior

**Insistence on sameness, inflexible adherence to routines or ritualized patterns of verbal or nonverbal behavior. [ ] yes [ ] no** Child is having difficulty with: [ ] distress at changes. [ ] transitions [ ] rigid thinking patterns. [ ] rituals/ compulsions Parent Report: [ ] Observations/ ADOS: [ ] Childcare/ School Questionnaire [ ]

Highly restricted, fixated interests abnormal in intensity/ focus

**Highly restricted, fixated interests abnormal in intensity/ focus [ ] yes. [ ] no ** Child is doing: [ ] strong attachment/ preoccupation with unusual objects [ ] preservative interests Parent Report: [ ] Observations/ ADOS: [ ] Childcare/ School Questionnaire: [ ]

Hyper/ hyporeactivity to sensory input

** Hyper/ hyporeactivity to sensory input [ ] yes [ ] no ** Child is doing: [ ] apparent indifference to pain/ temperature [ ] adverse response to specific sounds or textures [ ] excessive smelling or touched of objects [ ] visual fascination with lights or movements Parent Report: [ ] Informal and ADOS Observations: [ ] Sensory Profile Results: [ ] Childcare/ School Questionnaire: [ ]

BEHAVIOURAL AND EMOTIONAL REGULATION

Concerns with: [ ] tantrums. [ ] anxiety Parent Report: [ ] Informal and ADOS Observations: [ ] Childcare/ School Questionnaire: [ ]

DEVELOPMENTAL & ADAPTIVE SKILLS

Parent Report: [ ] Clinic Observations: School/ Childcare: [ ] GM/ FM Concerns: [ ] ADL Concerns with: [ ]

COGNITIVE/ Pre-academics

Concerns with: [ ] attention/ focus. [ ] overall academics Parent Report: [ ] Childcare/ School Questionnaire: [ ] Psychoeducational Testing Results? *ABAS – SEE PRINTOUT*

PHYSICAL EXAM

HT: [ ] WT:[ ] HC:[ ] H/N:[ ] Cardio:[ ] Resp:[ ] Abdo:[ ] Skin:[ ] Neuro:[ ] Dysmorphic:[ ]

Overall level of concern with Social Communication

[ ] Level 1 [ ] Level 2 [ ] Level 3 ** Level 3 Requiring very substantial support: Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning, very limited initiation of social interactions, and minimal response to social overtures from others. For example, a person with few words of intelligible speech who rarely initiates interaction and, when s/he does, makes unusual approaches to meet needs only and responds to only very direct social approaches. Level 2 Requiring substantial support: Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions; and reduced or abnormal responses to social overtures from others. For example, a person who speaks simple sentences, whose interaction is limited to narrow special interests, and who has markedly odd nonverbal communication. Level 1 Requiring support: Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social interactions, and clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social interactions. For example, a person who is able to speak in full sentences and engages in communication but whose to-and-fro conversations with others fail, and whose attempts to make friends are odd and typically unsuccessful.

Overall level of concern with BEHAVIOUR

[ ] Level 1 [ ] Level 2 [ ] Level 3** Level 3 Requiring very substantial support: Inflexibility of behavior, extreme difficulty coping with change, or other restricted/ repetitive behaviors markedly interfere with functioning in all spheres. Great distress/ difficulty changing focus of action. Level 2 Requiring substantial support: Inflexibility of behavior, difficulty coping with change, or other restricted/ repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress and/ or difficulty changing focus or action. Level 1 Requiring support: Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence.

Initial Impression

[Initial Impression]

Diagnostic Statement

[Diagnostic Statement]