Most questions on page 1 are required, such as: parent’s name, relationship to the child, child’s name, date of birth, and gender.  This information is used to customize questions on the remaining pages and responses on the final report.  For example, after the first page the child's first name will be inserted into questions wherever you see references to "CN" (which stands for "child name") in the questions listed below.  All references to "he/she" or "his/her" will also automatically be changed to the proper gender.

We recommend you keep the email address field so that you have some way of contacting the person filling out the form.

Your Information
1. Title of person completing this form:	Required
2. First name of person completing this form:	Required
3. Last name of person completing this form:	Required
4. Relationship to child (the client) of person completing this form:	Required
5. Email address of person completing this form:	Keep Delete
6. Do you know the date this child will be assessed by the professional who sent you this form?	Keep Delete
Child's Information
1. First name of the child being seen for this evaluation:	Required
2. Last name of the child being seen for this evaluation:	Keep Delete
3. Does this child have a nickname or informal name THAT MOST PEOPLE OUTSIDE OF THE HOME USE and that should be used to refer to him/her throughout this form?	Keep Delete
4. Child's date of birth:	Required
5. Child's gender:	Required

Question 1 below is required; however, the sub questions 1a through 1e may be kept or deleted.  We encourage you to keep all sub questions to question 1 as they allow for almost any living situation to be addressed.

1. Which applies to CN's living situation?	Required
a) Lives with both biological parents full time.	Keep Delete
b) Lives with one or both biological parents at least part time.	Keep Delete
c) Lives with one or both adoptive parents or legal guardians.	Keep Delete
d) Lives with one or both LGBT parents.	Keep Delete
e) Lives in foster care.	Keep Delete
2. PRIMARY language spoken to CN within the home:	Keep Delete
3. Are any additional languages spoken within the home?	Keep Delete
4. Has the family moved in CN's lifetime?	Keep Delete

1. Has CN had any SIGNIFICANT illnesses?	Keep Delete
2. Has he/she had any SIGNIFICANT injuries?	Keep Delete
3. Has CN ever required an overnight hospitalization (aside from immediately after his/her birth)?	Keep Delete
4. Has he/she ever undergone surgery?	Keep Delete
5. Does CN show signs of seizures?	Keep Delete
6. Has CN received most of his/her recommended childhood vaccinations?	Keep Delete
7. Has he/she had ear infections?	Keep Delete
8. Does CN have any seasonal/environmental, food, medication, or other allergies?	Keep Delete
9. Does he/she have asthma?	Keep Delete
10. Has CN ever been prescribed psychotropic medications (medication for psychological conditions such as ADHD, depression, anxiety, etc.)?	Keep Delete
11. Did CN pass his/her newborn hearing screening (a screening typically completed in the hospital within a few days of the child's birth)?	Keep Delete
12. Aside from CN's newborn hearing screening, has his/her hearing ever been tested/screened?	Keep Delete
13. Regardless of whether his/her hearing was tested, or the test results, do you have concerns about his/her hearing?	Keep Delete
14. Did CN pass his/her newborn vision screening (a screening typically completed in the hospital within a few days of the child's birth)?	Keep Delete
15. Aside from CN's newborn vision screening, has his/her vision ever been tested/screened?	Keep Delete
16. Regardless of whether his/her vision was tested, or the test results, do you have concerns about his/her vision?	Keep Delete
17. Does CN eat a good amount of food? (How picky he/she is and sensory issues will be addressed later. This question is asking about the amount or style of eating.)	Keep Delete
18. Sleeping - Going to bed	Keep Delete
19. Sleeping - Nightmares or night terrors	Keep Delete
20. Sleeping - Waking at night	Keep Delete
21. Sleeping - CN typically sleeps this many hours per night:	Keep Delete
22. Sleeping - Naps  (Question is only asked about children under 8 years of age.)	Keep Delete
23. Does he/she have pica (attempting to eat nonfood or nonedible items)?	Keep Delete
24. Does CN have difficulty with elimination (bowel movements)?	Keep Delete
25. Has he/she undergone any advanced medical testing, such as genetic testing, an MRI, a CT or CAT scan, or an EEG (typically done to rule out seizures)?	Keep Delete
26. Are there any other medical issues that have significantly affected CN that were not addressed in the medical questions above (e.g., acid reflux, eczema, anemia, etc.)?	Keep Delete

1. Please use two words to describe CN as an infant (his/her personality during the first 12 months of his/her life).	Keep Delete
2. When did he/she sit up without support?	Keep Delete
3. When did he/she start crawling?	Keep Delete
4. When did he/she first walk independently without support?	Keep Delete
5. Do you have concerns about CN's current motor skills, such as his/her gross motor skills (ability to walk, run, jump) or fine motor skills (ability to pick up or manipulate small objects)?	Keep Delete
6. When did he/she first use functional words? ("Functional" means the word was not just said in repetition of another person or said randomly but was used with clear intent and more than just once.)	Keep Delete
7. When did he/she begin combining words purposefully?  (This means intentionally putting two unique words together and not just using rote phrases such as, "What's that?")	Keep Delete
8. Do you have concerns about CN's current language skills (such as the size of his/her vocabulary, articulation issues, ability to combine words in an age-appropriate manner, or social use of language)?	Keep Delete
9. At what age was he/she toilet trained?	Keep Delete
10. Has CN ever significantly regressed in his/her development or skills?  In other words, did he/she ever lose the ability to use words or the desire/ability to socially engage others?	Keep Delete

1. Auditory (sounds)	Keep Delete
2. Visual (light)	Keep Delete
3. Olfactory (smells)	Keep Delete
4. Oral / Foods	Keep Delete
5. Tactile (touch)	Keep Delete
6. Clothes	Keep Delete
7. Vestibular (movement)	Keep Delete
8. Proprioceptive (pressure)	Keep Delete
9. Pain tolerance	Keep Delete
10. Activity level (over- or underactive)	Keep Delete
11. Focus or attention span	Keep Delete

1. Did CN receive services prior to 3 years of age, such as from a regional center, department of education, or insurance company?	Keep Delete
2. Has CN attended day care?	Keep Delete
3. Did he/she attend a preschool program between 3 and 5 years of age?  (Question is only asked about children over 3 years of age.)	Keep Delete
4. Has CN attended kindergarten?  (Question is only asked about children over 3 years of age.)	Keep Delete
5. What grade is CN currently attending?  (Question is only asked about children over 3 years of age.)	Keep Delete
6. Has CN ever been evaluated for an IEP or special education services?  (Question is only asked about children over 3 years of age.)	Keep Delete
7. Does CN have behavioral difficulties within his/her current school or program?	Keep Delete
8. Has CN ever been evaluated for speech therapy?	Keep Delete
9. Has CN ever been evaluated for occupational therapy?	Keep Delete
10. Has CN ever been evaluated for physical therapy?	Keep Delete
11. Has he/she ever been evaluated for autism intervention services such as ABA?	Keep Delete
12. Has CN ever been evaluated for developmental therapy?	Keep Delete
13. Has he/she ever received any other therapies (for example: music therapy, equestrian therapy, feeding therapy, etc.)?	Keep Delete
14. Has CN participated in organized extracurricular activities such as scouts, karate, soccer team, swim lessons, music lessons, etc.?	Keep Delete

1. Do you believe CN has visual or auditory hallucinations?  (Question is only asked about children over 5 years of age.)	Keep Delete
2. Has he/she ever been hospitalized due to a psychological issue (i.e., 5150 due to being a risk to himself/herself or others)?  (Question is only asked about children over 5 years of age.)	Keep Delete
3. Has CN expressed suicidal or homicidal thoughts?  (Question is only asked about children over 5 years of age.)	Keep Delete
4. Has he/she been the victim of abuse, neglect, and/or trauma, or has he/she had Child Protective Services (CPS) involved in his/her life?	Keep Delete
5. Is there a family history of any learning disabilities or psychological issues within the last two generations of CN?	Keep Delete
6. Do you believe he/she has fears or anxiety more than most children his/her age?  (Many young children have normal fears such as being afraid of the dark or dogs, or they may be initially hesitant around strangers.)	Keep Delete
7. Do you believe CN has significant signs of depression?	Keep Delete
8. Does he/she INTENTIONALLY try to hurt himself/herself?	Keep Delete
9. Does he/she INTENTIONALLY try to hurt OTHERS?	Keep Delete
10. Does CN have excessive tantrums or more than you would expect for his/her age?	Keep Delete
11. Has he/she ever received counseling services, such as through a therapist or mental health agency?	Keep Delete
12. Has CN consumed alcohol, used substances (e.g., marijuana, cocaine, prescription meds not prescribed to him/her, etc.), engaged in huffing, etc.?  (Question is only asked about children over 11 years of age.)	Keep Delete
13. Has CN committed a crime that involved authorities? (e.g., been caught engaging in theft, vandalism, abusing others, etc.)  (Question is only asked about children over 11 years of age.)	Keep Delete
14. Has CN been employed or legally held a job?  (Question is only asked about children over 14 years of age.)	Keep Delete

1. Has CN ever previously been evaluated for, or diagnosed with, a psychological disorder (such as autism, depression, language disorder) by a professional (such as a psychiatrist, psychologist, or counselor)?	Keep Delete
2. Please BRIEFLY describe who initially brought up concerns about autism and/or developmental delays and/or who referred you for the current evaluation.	Keep Delete
3. The examiner will ask about many of your responses to this questionnaire when you meet with him/her in person.  Are there any specific issues the examiner needs to know in advance prior to meeting with you?	Keep Delete