Child and Adolescent-Autism Intake

YOUR CHILD’S NAME:

NICKNAME:

DATE OF BIRTH:

AGE:

ADDRESS:

YOUR TELEPHONE:

Add Another Phone Number

DATE QUESTOINNAIRE COMPLETED:

COMPLETED BY:

RELATIONSHIP:

Who referred you to us?

Why?

Information about the Child and Family

Child’s Sex:

Male Female

Mother’s Name:

Age:

Occupation:

Mother completed:

High School:

Some College:

College Graduate:

Father’s Name:

Age:

Occupation:

Father completed:

High School:

Some College:

College Graduate:

Child currently lives with:

Child’s legal guardian (s):

Other children in the family:

NAME:

Age:

List any problems or special needs:

Add Another Child

Are there other people in the home?

Yes No

What is their relationship to your child?

Are there pets in your home?

Yes No

If yes, please list:

Do you live in:

an apartment mobile home house

What is your child’s current diagnosis?

Who made this diagnosis?

What age was your child when the diagnosis was made?

PLEASE LIST YOUR CURRENT MAJOR CONCERNS ABOUT YOUR CHILD (tell us how we can help):

How old was your child when you first became concerned?

Please tell us what you noticed early on in your child’s development:

Does your child play with toys in typical ways?

Yes No

If no, please describe:

Does your child seem to focus on only certain parts of toys or objects?

Yes No

Does your child seem overly pre-occupied with certain objects, toys, videos, or subjects?

Yes No

Does your child have difficulty relating to people?

Yes No

Does your child emotionally overreact to certain situations?

Yes No

Does your child have good eye contact?

Yes No

Does your child look at objects out of the corner of his/her eyes?

Yes No

Does your child ever look at objects from unusual angles?

Yes No

Does your child ever engage in self-injurious behaviors (eg., headbanging, eye-poking, picking at skin, hitting himself)?

Yes No

Does your child ever show aggression to others?

Yes No

Does your child frequently have temper tantrums?

Yes No

Does your child walk on tiptoes?

Yes No

Does your child rock back and forth or side to side?

Yes No

Is your child overly active or underactive?

Yes No

Does your child frequently have trouble sleeping?

Yes No

Does your child ever seem depressed?

Yes No

Does your child ever threaten to harm himself/herself?

Yes No

Does your child cover his/her ears in response to certain sounds or for no apparent reason?

Yes No

Does your child ignore unusually loud noises (sirens, vacuum cleaner)?

Yes No

Is your child bothered by tags in his/her clothing?

Yes No

Does your child frequently smell, touch, or lick objects or people?

Yes No

Does your child ever eat things that are not food?

Yes No

Does your child ever pull out his/her hair?

Yes No

Does your child ever eat his/her own hair?

Yes No

Does your child collect certain things or objects?

Yes No

Does your child seem pre-occupied with turning over your furniture or turning objects upside-down?

Yes No

Does your child insist on cupboards and doors being all open or all closed?

Yes No

Does you child complain when he/she is injured

Yes No

Does your child seem overly fearful or lack safety awareness?

Yes No

Does your child have difficulty learning compared to other children the same age?

Yes No

Does your child ever mimic, echo, or repeat previously heard words or phrases?

Yes No

Does your child ever repreat phrases from television commercials or videos over and over?

Yes No

Does your child ever act out portions of videos or TV shows over and over?

Yes No

Does your child become upset if routines are changed?

Yes No

Does your child do some things in the same way over and over again?

Yes No

Does your child seem interested in people?

Yes No

Does your child seem interested in peers?

Yes No

Is your child affectionate?

Yes No

Does your child form friendships?

Yes No

Does your child play with other children?

Yes No

Does your child prefer to be alone?

Yes No

Please list your child’s previous psychiatric treatment below:

Inpatient:

Date:

Facility:

Reason for Admit:

Diagnosis:

Add New Inpatient Entry

Outpatient:

Date:

Facility:

Type of Tx:

Frequency:

Diagnosis:

MD/ Case Manager:

Add New Outpatient Entry

Please tell us about the medications and/or supplements that have been tried with your child in the past by completing the table below.

If you answer yes to each current medication, please provide the "Dose/Include Maximum Dose Tried", "Date/Length of Trial", and "RESULTS/Reason for stopping (side effects)". Otherwise, please leave these empty.

STIMULANTS:

Ritalin

Yes No