Member
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| Non-Member
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| Parents
First Names: |
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| Home Phone
#: |
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| Child's
Name: |
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| Nickname: |
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| Child's
Birthday |
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| Brother's/Sister's
Names and Age: |
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Other
significant adults: (Aunt/uncles/grandparents):
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| Family
Pets: |
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| Favorite
activities at home: |
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| Other activities: |
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| Through
school: |
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| Outside
of school: |
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| Favorite
places to go: |
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| Does
your child have a medical or educational diagnosis
on the Autism /Spectrum: |
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| What
made you seek special help for your child? At
What age did you seek help? Tell me your story. |
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| Sensory
Issues: Touch |
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| Clothing: |
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| Clothing
tags a problem: |
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| New Clothing: |
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| New Shoes: |
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| Trying
on clothing or shoes: |
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Hair
Care: (Hair cut, washing hair, brushing hair)
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| Nail care: |
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| Temperature: |
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| Wants
to only wear long/short sleeve shirts:
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Wants
to only wear long/short pants:
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| Wants jacket
zipped to neck: |
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| Likes to
wear hood tied: |
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| Likes to
wear hats: |
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| Difficulty
switching clothing seasonally: |
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| Bathing: |
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Likes
to be hugged tight, massaged, lotion:
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| Tell me
your story below: |
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| Sensory
Issues: Taste/Texture of Food |
| Sits at
table to eat: |
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| Do you
think your child is a picky eater: |
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| Limited
food variety: |
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| Food your
child likes: |
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| Food dislikes: |
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| Food refuses
to eat: |
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| Favorite
fast food: |
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| Favorite
snack at home: |
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| Sweet,
salty, crunchy, soft: |
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Your
impressions below:
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| Sensory
Issues:
Sound |
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| Sensitive
to noises; Noisy places |
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| Crowded
places: |
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| Loud noises: |
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| Covers
his/her ears: |
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| Your
impressions below: |
| Sensory
Issues:
Light |
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| Covers
eyes frequently, especially in bright places |
| Plays
with light, waving/wiggling fingers around eyes |
| Likes
to be in snug places protected from light (under
a cover, in the closet, under the table, etc |
Your
impressions below:
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| Has
your child had Sensory Therapy with an Occupational
Therapist ? |
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| Communication |
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| Language
Development: Makes sounds while playing,
expresses pleasure, fear, anger using different
pitch and loudness of sounds. |
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| At
what age did your child do these things?
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| Does
your child attempt to communicate these things?
Yes or No:
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| Will
your child look at books with you point to pictures?
Y/N:
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Your
impressions below:
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| How
does you child attempt to communicate to you
what he/she wants or desires? |
| Tries to
communicate verbally: |
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| Grunt &
point: |
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| Take you
to the desired item: |
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| Use gestures
to help you understand: |
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Your
impressions below:
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| Likes
to play interactive games such as Peek-a-boo,
Where did it go? Gestures with songs, Itsy Bitsy
Spider, Jack & Jill, Swing me around… |
Your
impressions below:
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| Preverbal
Communication: |
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Use
picture or object communication system:
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| Use sign
language to communicate: |
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| Verbal
Communication |
Use
single word, or phrases to let you know what
he/she wants. Give me some samples below:
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| Use
memorized verbal "scripts" from TV,
videos or books to communicate. |
Give
me some samples below:
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Uses
questions to ask for something. Do you want
a cookie? Imitating what you would say in that
situation. Give me some samples below:
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Are
you able to communicate your needs and wants
to your child. What he/she needs to do, what
you want him/her to do?
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Has your child had Speech & Language Therapy
Services:
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| Independant
Skills: Please Describe |
Dressing:
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Eating:
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Toilet:
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Bath:
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Sleep:
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Any
Other Difficult Times at Home? Please Describe
Your Concerns.
Safety Issues, Home, Car, Away From Home, Visiting
Family, Vacations…… Please Describe:
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| Social
/ Play Concerns |
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Is
your child's play more like a ritual that he/she
does not want interrupted?
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Does
your child line up toys? Pick out specific colors
of items: Allow you to participate in play routines:
What are your child's favorite toys? Favorite
songs, videos, etc.
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Please
Read and put your initials in the box below.
We are not currently involved in a lawsuit,
nor do we anticipate being involved in any legal
activity.
I am not a legal expert. The opinions I express
are based on my personal experience. I do
not want to be involved in any legal battles
that families may have with their School District,
or other professionals. I will not become
involved in legal issues. I am not preaching
"Gospel" of what is legal or not
legal. This is very important to me.
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