Autism Evaluation Intake Form

CHILD’S PERSONAL INFORMATION

Today’s Date:
Child’s Name: M F Age: Birthdate:
Referred by: ___________________________ Specialty:
Why do you want your child evaluated?

CURRENT CONCERNS ABOUT YOUR CHILD

Please check all that apply:

 aggression  has few friends  has no friends

 overactivity  language difficulties  toilet training
 preoccupations  temper tantrums  biting
 hitting  self-injury  sleep problems
 sleeps in parents’ bed  has nightmares  nervousness
 argumentative  easily distracted  self-help skills
 won’t take baths  appetite/food selections  eats things that aren’t food
 wets the bed  pulls out own hair  inattentive
 school adjustment  cruel to animals  inappropriate sexual behavior
 motor skills  depressed or anxious  muscle tone
 self-stimulatory behaviors: rocking, spinning, flapping hands, visual scrutiny
 Other:
Please provide detail for any items checked above:

What is the biggest problem?

How long has it been a problem?

What do you think caused it?

What seems to upset the child?

What seems to calm the child?

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CHILD’S CURRENT LIVING SITUATION
With whom does the child currently reside? (please mark all that apply)
 Biological Mother  Biological Father  Step-mother  Step-father
 Adoptive Mother  Adoptive Father  Foster Mother  Foster Father
 Grandparent
 Other (describe: ________________________________________________)

Complete the following for the child’s BIOLOGICAL PARENTS to the best of your ability, even if
you are not the child’s biological parent.

Biological Mother’s Name: Age: ______ Birthdate:

Occupation: Ethnic/Cultural Background:
Work Phone: Home Phone: _______________
Cell Phone:

Biological Father’s Name: Age: ______ Birthdate:

Occupation: Ethnic/Cultural Background:
Work Phone: Home Phone: _______________
Cell Phone:

If child does not live with BOTH biological parents, who has legal custody of the child?

If the child currently resides with parents OTHER than biological parents, please describe them here.
Parent/Caretaker One’s name: Age: ______ Birthdate:
Relationship to child:  Adoptive Parent  Step-Parent  Foster Parent  Grandparent
 Parent’s partner  Other:
Occupation: _________________________ Ethnic/Cultural Background:
Work Phone: ________________________ Home Phone: _____________________________

Parent/Caretaker Two’s name: Age: ______ Birthdate:

Relationship to child:  Adoptive Parent  Step-Parent  Foster Parent  Grandparent
 Parent’s partner  Other:
Occupation: _________________________ Ethnic/Cultural Background:
Work Phone: ________________________ Home Phone: _____________________________

Highest level of education by each parent:

Biological Mother Biological Father Parent 1 (above, if app.)Parent 2 (above, if app.)
 11 grade or less  11 grade or less  11 grade or less  11 grade or less
 GED  GED  GED GED
 High school grad  High school grad  High school grad High school grad
 Associates Degree  Associates Degree  Associates Degree Associates Degree
 Bachelor’s Degree  Bachelor’s Degree  Bachelor’s Degree Bachelor’s Degree
 Graduate/Professional  Graduate/Profess. Graduate/Profess. Graduate/Professional
 Vocational Certificate  Vocational Cert.  Vocational Cert. Vocational Certificate

How often does the other biological parent see this child?

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Number of years married/together: ________ Approximate date of divorce/separation:
Number of times married: Mother ______ Father ______
If child is with ADOPTIVE parent, age child was first in home: _____ Date of legal adoption:
What has the child been told about the adoption?

If your child spends a significant amount of time with a caregiver other than someone described
above (i.e., spends more than 4 hours/day) EXCLUDING school personnel, please complete the
following information for that person here:
Name: Age: ______ Birthdate:
Relationship to Child: Ethnic/Cultural Background:
Occupation: Highest Level of Education:

Siblings: (please list whether the siblings live in the child’s home or not)
Name Age M/F Full/Step/Half? Grade In child’s home?

Other occupants of child’s residence NOT listed above:

What languages does the child use (List PRIMARY language first):
What other languages is your child exposed to?

DEVELOPMENTAL HISTORY
(If re-evaluation, please skip to “Medical History” on page 5 and add any updates.)

Prenatal/Pregnancy
Did the biological mother have any of the following immediately before/after or during pregnancy?
 Maternal injury. Describe:
 Hospitalization during pregnancy. Reason:
 X-rays during pregnancy. What month of pregnancy?

Did the biological mother have any of the following during pregnancy?
 Emotional problems  Infections  Premature Labor
 Rashes  Bed-rest  Toxemia
 Difficulty in conception  Anemia  Gained more than 35 pounds
 Excessive swelling  Vaginal bleeding  Measles/German measles
 Excessive nausea/vomiting  Flu  High blood pressure
 Kidney disease  Strep Throat  Threatened miscarriage
 Rh incompatibility  Headaches  Severe cold
 Urinary problems  Other virus
 Special diet, describe: _________________________  Meds:
Other:

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Mother’s age at conception: __________
Did the mother have previous pregnancies?  No  Yes--how many, including miscarriages?

Did mother receive prenatal care during this pregnancy?  No  Yes--beginning at month
During the pregnancy, was the baby:  Very active  Average  Rather quiet
Were there any unusual changes in the baby’s activity level during pregnancy?  No  Yes

Delivery
Was infant born full-term?  Yes  No
If premature, how early? If overdue, how late?
Birth weight: Apgars: at 1 minute ______ at 5 minutes
Type of anesthetic used:  None  Spinal  Local  General
Length of active labor: Describe any complications during delivery:

Check all of the following that applied to the delivery:

 Spontaneous  Breech  Forceps
 Head first  Multiple births  Cord around neck
 Induced; Reason: ______________________________________
 Cesarean; Reason: _____________________________________

Which of the following applied to the infant? (check all that apply)
 Breathing problems  Required oxygen  Required incubator
 Jaundice (Were Bilirubin lights used?  No  Yes – How long? _________)
 Feeding problems  Sleeping problems  Infection
 Rash  Excessive crying  Seizures/convulsions
 Unusual appearance, describe: ____________________________
 Bleeding into the brain

Did the infant require:  X-Rays  CT scans  Blood transfusions

 Placement in the NICU (If so, for how long? __________)

Length of stay in hospital: Mother ___________ Infant ___________

Early Childhood History

During this child’s first three years, were any special problems noted in the following areas?
 Irritability  Breathing problems Colic
 Difficulty sleeping  Eating problems  Temper tantrums
 Failure to thrive  Excessive crying  Withdrawn behavior
 Poor eye contact  Early learning problems  Destructive behavior
Convulsions/Seizures  Twitching  Unable to separate from parent
Other _______________________________________________________________________

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Milestones - Indicate age when child:
______ sat unaided _____ crawled ______ walked
______ started solid foods _____ fed self with spoon ______ gave up bottle
______ bladder trained-day _____ bladder trained-night ______ bowel trained
______ rides tricycle _____ rides bike

Can child be described as clumsy/uncoordinated?  Yes  No

Having fine motor delay?  Yes  No
Which hand does your child use for: Writing/drawing? Eating? Cutting?
Current eating behavior:  Normal  Picky  Eats too much  Weight loss/gain
Oral Motor concerns  None  Difficulty swallowing  Drooling  Gagging

Language development
Indicate age when child begin babbling, such as repeating syllables, in attempts to communicate:

Using single words? Using phrases/short sentences?

Have there been any hearing concerns?  No  Yes Hearing testing – date?

Adaptive Skills
Feeds self  No  Yes, beginning at age _______
Dresses self No  Yes, beginning at age _______
Bathes self  No  Yes, beginning at age _______
Helps with household chores  No  Yes, beginning at age _______
Knows first and last name  No  Yes, beginning at age _______
Says “please” and “thank you”  No  Yes, beginning at age _______
Able to walk up/down stairs  No  Yes, beginning at age _______

Has the child ever lost skills, which at one time he/she was able to perform?  No  Yes
If yes, please explain
When your child is disruptive or misbehaves, what steps are you likely to take to deal with the
problem?
 Time out  Loss of allowance/privileges  Physical punishment  Yelling
 Ignoring  Grounding  Other, describe
Who is mainly in charge of discipline?
What do you find most difficult about raising your child?

MEDICAL HISTORY
Has your child ever had:

Head injury Age _____ Describe

Loss of consciousness Age ____ How long?
Describe
Allergies to food/medication List:

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Surgery - Age_____ Reason
Describe
(if more than one surgery, please list on back)

Ear Infections: Age ____ Describe

Ear tubes?  No  Yes Date of surgery
Is the child up to date on immunizations?  Yes  No, Why not?

Doctors seen (check all that apply)

 Pediatrician – Date of last visit: _________ Diagnosis:
___________________________________
 Developmental Pediatrician – Date: ______ Diagnosis:

 Neurologist – Date: __________ Diagnosis:

suspected seizures, describe:
seizures diagnosed, type:
 Genetics – Date: Diagnosis:
 Psychiatry – Date: Diagnosis:
 Psychology – Date: Diagnosis:
 Gastroenterology – Date: ________ Diagnosis:
stomach/intestinal problems, type:
 Endocrinology – Date: _________ Diagnosis:

Diagnostic Testing (check all that apply)

 EEG (brain wave test) – Date: _______ Results:

 MRI – Date: _______ Results:
 CT Scan – Date: _________ Results:
 Ophthalmology Evaluation – Date: ________ Results:
 Chromosomal/DNA testing (Genetics) – Date: ________ Results:
 Other - Describe:

Medication history

CURRENT medications (PLEASE NOTE: DO ADMINISTER child’s regularly scheduled

medications, if any, on the day of your appointment.)
Name of medication Dose & Frequency Date Started Reason Effectiveness

Who prescribes these medications? ________________________ Date of last visit:

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Please also list any medications your child has been on in the PAST:

Name of medication Dose & Frequency Date Started/Ended Reason Effectiveness

Who prescribed past medications?

CHECKLIST: Please mark any of the following in each area that describe your child currently or in
the past:
Speech
Past Current Past Current
  slow speech development   doesn’t understand without gestures
  unusual tone or pitch   repeats words/phrases over and over
  difficult to understand speech   repeats questions, instead of answering them
  seldom speaks unless prompted   repeats dialogue from movies/songs verbatim
  has language of his/her own (may sound like foreign language/jargon)

Relating with other people

Past Current Past Current
  prefers to be by self   “in a world of his/her own”
  aloof, distant   clings to people
  fearful of strangers   not cuddly as baby
  doesn’t like to be held   doesn’t recognize parent
  doesn’t play with other children
  prefers playing with younger or older children

Imitation
Past Current
  doesn’t imitate waving “bye-bye” or “patty cake” etc. (physical imitation)
  doesn’t repeat words/things said to him
  doesn’t repeat words generally, but usually did what he was asked to do

Response to Sounds, Speech

Past Current Past Current
  often ignores sounds   often ignores what is said to him/her
  afraid of certain sounds   really likes certain sounds (music, motors, etc.)
  seems to hear distant or soft sounds that most other people don’t hear or notice
  unpredictable response to sounds (sometimes reacts, sometimes doesn’t)
  responds to speech and sounds like other children of the same age

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Visual Response
Past Current Past Current
  stares vacantly around room   plays with turning lights on and off
  often doesn’t look at things   distracted by lights – stares at certain lights
  likes to look at self in mirror   very interested in small parts of an object
  likes to look at shiny objects   looks at things out of the corners of eyes
  stares at parts of his/her body (e.g. hands)
  often avoids looking at people when they are talking to him

Other Senses
Past Current Past Current
  puts many objects in mouth   likes vibrations
  licks objects   doesn’t notice pain as much as most people
  overreacts to pain   smells objects unusual or unfamiliar objects
  chews or eats objects that are not supposed to be eaten

Emotional Responses
Past Current Past Current
  temper tantrums   laughs/smiles for no obvious reason
  overly responds to situations   moods change quickly/for no apparent reason
  cries/seems sad for no obvious reason   often has blank expression on face
  little response to what is happening around him/her

Name some GOOD things about the child:

1. _____________________________________________________________
2. _____________________________________________________________
3. _____________________________________________________________
4. _____________________________________________________________

FAMILY MEDICAl/PSYCHIATRIC HISTORY

Have any members of the biological mother’s or biological father’s families had any of the following problems
or disorders (check all that apply):
 Birth Defect Chromosomal/genetic disorder  Obsessive Compulsive Disorder
 Cerebral Palsy  Severe head injury  High blood pressure
 Kidney disease  Migraine headaches  Multiple Sclerosis
 Physical handicap  Nervousness/Anxiety  Stroke
 Tuberous Sclerosis  Alzheimer’s disease  Hemophilia
 Huntington’s chorea  Muscular dystrophy  Parkinson’s disease
 Sickle-cell anemia  Cancer  Seizures/epilepsy
 Diabetes  Heart disease  Food allergies
 Alcohol/drug abuse  Depression  Physical/Sexual abuse
 Schizophrenia  Mental Retardation  Speech/language delay
 Autism/PDD  Reading problem  Other learning disability
 Emotional disturbance/mental illness  Bipolar/manic-depressive disorder
 Tics/Tourette’s syndrome  Antisocial Behavior(assaults, thefts, arrests)
Childhood behavior disorder (aggressive/defiant/ADHD)
Other:

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Has anyone in the family ever received special education services?  No  Yes - for what reason?

Family Changes and Stressors: Please indicate any major family stresses the family and/or child is
currently experiencing or has experienced within the last year.
 Marital discord/fighting  Separation  Divorce
 Birth/Adoption of another child  Sibling conflict  Parent-Child conflict
 Custody disagreement  Single-parent family  Parent/sibling death
 Parent deployed extensively  Parent emotionally/mentally ill
 Involved in juvenile court  Abandonment by parent  Financial problems
 Parent substance abuse  Child Neglect  Physical abuse
 Sexual abuse  Parental disagreement about child-rearing
 Involved with Social Services/Child Protective Services
 Other, if not listed:

SCHOOL HISTORY
(If more space is necessary, please attach additional sheets or write on the back of this page.)
Current school: School district:
Grade level:
Type of class:  Regular Ed  Special Ed  Resource  ED  Behavioral unit
Current # of: Students ____ Teachers ____ Aides ____ Does your child have a 1:1 Aide?
Has your child had special education testing in school?
 Psychological/Cognitive – Date: __________  Academic – Date: ____________
 Speech/Language – Date:  Other: ___________________ Date: _________
Is your child receiving any special education services at school?  Yes  No
Is your child on an IEP (Individual Education Plan)? ____ For what reason?
Please list all of the schools, including preschools, your child has attended:
Name of school Age/grade attended Hours per day Days per week

SERVICES - Please list services your child has received.

(Please bring copies of your most recent Individual Education Plan (IEP))

Child’s age when school services began:

Individual Education Plan (IEP) eligibility:
Which services is your child CURRENTLY receiving through the SCHOOL DISTRICT?
 Speech therapy  Occupational therapy  Physical therapy
 Adaptive Physical Education  Discrete Trial Training (DTT/ABA)  Social Skills
 Other - describe:

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Early Childhood Intervention (ECI): (Please bring copies of your most recent ECI, Individual Family
Service Plan (IFSP), and relevant reports to your appointment.)

Is your child currently a client of ECI?  Yes  No (skip to Private Services)

Which ECI Center: ________________________________ Eligibility category:

Child’s age when ECI services began:

Which services is your child CURRENTLY receiving through the REGIONAL CENTER?
 Speech therapy  Occupational therapy  Physical therapy
 Adaptive Physical Education  Discrete Trial Training (DTT/ABA)  Social Skills
 Other - describe:

Private Services (Please bring copies of relevant reports to your first appointment.)
Are you or your insurance company currently paying for services to address your child’s needs?  Yes  No
 Speech therapy Provided by: _______________________ Age when began: ______
 Occupational therapy Provided by: _______________________ Age when began: ______
 Physical therapy Provided by: _______________________ Age when began: ______
 Adaptive Physical Education Provided by: _______________________ Age when began: ______
 Social Skills Provided by: _______________________ Age when began: ______
 Discrete Trial Training(DTT/ABA) Provided by: ______________________ Age when began:
 Other - describe:

Please bring this completed intake form to your first appointment.

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