ASD 6-18 YEARS PARENT QUESTIONNAIRE

Child's Details

Child’s Surname *

Given Names *

Date of birth: *

Gender

MaleFemaleOther

If other, please list preferred pronoun

Name of Person Completing this Form and Relationship to the Child *

Mobile Phone *

E-mail Address *

Address

Street address

City

State

Postcode

Medicare

Parent's Medicare Number *

Child's Reference Number on the Card (e.g. 1, 2) *

Parent's Full Name as on Medicare Card *

Medicare Expiry Date *

Parent's Date of Birth for Medicare Billing *

School Details

Child's School *

Year Level/Grade *

Teacher Name

Referral

Was your child referred for an Autism Spectrum Disorder (ASD) assessment

YesNo Self-referral

If yes, who referred your child for the test?

Background Information

Does your child have any siblings?

YesNo

If yes, please state names of siblings and ages

Who does the child live with (please list all who live with the child)?

Has your child had speech/language development issues?

YesNoUnsure

If yes, please comment

Has your child had physical/motor skills difficulties?

YesNo Unsure

If yes, please comment

Has your child had grommets in the past?

YesNoUnsure

If yes, please provide number of times grommets inserted and year of insertions

Has any family member had speech/language/learning difficulties?

YesNoUnsure

If yes, please comment

Please comment on your child's current health

If yes, please name the specialist and when they were consulted

Please list other professionals not listed above who have been consulted

Has your child been placed on regular medication?

YesNo

If yes, please list the medication

Medical History

Was there anything unusual about the pregnancy?

YesNo

If yes, please explain

Does the child have any diagnosed medical condition?

YesNoUnsure

If yes, please list

Does the child have any developmental diagnosis e.g. (Global Developmental Delay, Attention Deficit Hyperactivity Disorder (ADHD))?

YesNoUnsure

If yes, please list

Developmental History

At what age did your child sit up unassisted?

At what age did your child walk unassisted?

At what age did your child say their first true word?

At what age did your child begin putting 2 words or more together?

Social & Emotional Reciprocity

Did you have any concerns regarding your child's ability to engage with others when they were between 1-3 years of age?

YesNo Unsure

If yes or unsure, please comment

How would you describe your child's social skills presently (do they seek to engage with others, or do they prefer to be on their own, do they engage with a preferred age group etc.)?

Does your child understand social conventions such as sharing, waiting and taking turns, losing? Can you provide some examples.

Does your child seek to share their interests with you? If so, how do they go about doing this ?

Does your child share experiences (theirs or someone else’s) such as joy from receiving a gift or winning a game?

Is your child able to initiate and sustain an age appropriate two way conversation? Can you provide some examples. (E.g. Do they have preferred topics, do they listen to what others have to say, do they have a back and forth chat about a variety of topics; speak out of context)?

Are there any concerns regarding their use or response to physical contact and affection (with you or other close family members)?

Do you have any concerns about your child’s emotional responses? What is their usual response when upset (how often do they get upset and do they seek consolation, how much consolation do they require, any changes as they have gotten older)?

Do you always understand the reason why your child is upset? Does the reaction seem appropriate? Can your child talk about why they are upset?

What are the most common reasons for them becoming upset?

Does your child recognise when another person is upset, hurt or unwell (how do they typically react)?

Does your child offer help others? Do they accept help from others?

Non-Verbal Responses

Do you have any concerns regarding your child’s eye contact (do they often look at the person speaking to them to engage)?

Does your child vary their facial expressions (express a range of expressions e.g. confused, stressed, engaged)?

Prior to your child using language, were they able to make their needs known by using gesture e.g. pointing, mime, did they take you by the hand and lead you to what they wanted?

Does your child use a range of gestures (using hands to imitate opening a door or using hands to explain an action)? Are they appropriate to the social context?

Do they understand how to use their body e.g. facing their body toward another person when speaking to them, personal space?

Can they recognise and interpret nonverbal behaviours of others such as facial expression and body language (e.g. frowns and arms crossed)?

Is there anything unusual about the quality of your child’s speech such as tone, volume, accent, expression?

Maintenance of Relationships

Do you think your child can understand and respond to the feelings of others? (E.g. understand why the other person might be feeling a particular way in a particular situation, feel pleased for another person when they’ve done well, spontaneously give compliments or praise, be considerate of someone else’s feelings)

Would you child be aware if they had offended or upset others? Do they understand the consequences of their behaviour e.g. the impact it might have on others such as the class or the family?

Do they only see things from their perspective? Do they understand that other people like things they may not like?

How do they react to teasing or joking around, by adult or by other children?

Does your child ever make socially inappropriate statements or ask socially inappropriate questions?

What is your child like at making and keeping friends? Do they have a preferred group of children they play with or a preferred friend? Describe their friendships and how they play?

Are they/were they ever invited to other children’s homes to play? Birthday parties?

Is your child imaginative in their play? If so, describe (e.g. can they make up stories on make believe characters)?

Stereotypical Behaviours

Have you ever had any concerns about the manner in which your child speaks (E.g. overly formal or pedantic, excessive parroting of what other’s say, using words or phrases repetitively or out of context, talking in “goobledegook”, making unusual noises or vocalisations.) If so, please provide some examples.

Have you ever noticed your child engaging in any unusual motor movements such as rocking or flapping, finger flicking, body posturing, grimacing, foot to foot rocking?

Does your child have any unusual collections or hoard items?

Routines

How has your child responded to major changes (e.g. holidays, moving house, starting /changing kindy or school)?

How do they respond to smaller changes (moving furniture around, doing your hair a different way, changing activity, driving a different way, growing out of clothing, relief teacher / change of school routine / going to a new place?)

How does your child cope with transitions (moving from one activity to another)?

Does your child have to finish what he/she is doing before having to stop or changing to another activity? How do they react of they are interrupted e.g. power goes out, dinner is ready? Please provide examples

Does your child have a strong sense of justice/injustice or right/wrong? Please explain

Restricted and Fixated Interests

Does your child have, or has your child had, an attachment to an unusual inanimate object (e.g. piece of string, rubber band)? Had to carry or hold specific or unusual objects? Please explain

Reactivity to Sensory Input

When younger, did your child stiffen, flinch or pull away when being held e.g. when feeding, changing, bathed?

Were there any problems when younger or now with any grooming (hair washed or brushed, face or mouth washed or touched, teeth cleaned, hair or nails cut, showers/ baths) activities?

Are there any issues around the clothing your child will wear (e.g. tags, seams, logos, dressing for temperature?)

Does your child have a high or low pain threshold? Please provide examples

Does your child lick/chew/mouth objects/food/people? Please provide examples

Does your child over or under react to unexpected sounds (e.g. puts hands over ears, mechanical or machine sounds, has to be taken out of ‘noisy’ environments, asks parents to turn car radio down etc)?

Does your child sniff objects/food/people?

Does you child have any trouble with food textures/colours? Please provide examples

General

Is there anything more you would like us to know about your child?

What are your child's strengths?

What are you most concerned about with regards to your child's development?

Do you feel that your child has concerns about their abilities?

Collection Statement

Allied Health Services

SASHC is required to collect and record personal information about you and your child in order to provide quality allied health services. This may include assessing, diagnosing and providing therapy. This information is relevant to your child’s situation, such as your child’s name, contact information, medical history and other relevant information as part of providing services to you. This collection of personal information will be a necessary part of the assessment and/or treatment that is conducted.

Purpose of Collecting and Holding Information

All personal information gathered as part of your child’s assessment and treatment, is kept securely. In the interest of your child’s privacy this information is only used by your child’s therapist/s and authorised SASHC staff . Your personal information is retained for record keeping purposes and enables your child’s therapist to provide a relevant and informed service to you/your child. A more detailed description is provided in the SASHC “Privacy Policy”. This policy is available to you on request.

Access to client information

At any stage you are entitled to access your child’s personal information kept on file, subject to exceptions in the relevant legislation. SASHC will discuss with you your different possible forms of access.

Disclosure of personal information

All personal information gathered by SASHC during the provision of allied health services will remain confidential, however, please note that by signing and acknowledging this document, you accept that information will be shared with other allied health professionals involved in your child’s care.

Please notify us if you do not wish us to disclose this information or if a child protection/court order is in place.

Audio/Video Recording

As a therapeutic clinic, we often make recordings of sessions and assessments for both analysis and planning. We may also utilise some of these recordings for teaching purposes. Your recordings will be kept secure and will not be shown to individuals not associated with our practice/clinic.

On behalf of SASHC, we undertake that, in respect of any audio/video recordings made, every effort will be made to ensure professional confidentiality and that any use of these audio/video recordings, or descriptions of audio/video recordings will be for professional use only and in the interest of improving professional standards through research and training programmes. Every effort will be made to ensure the anonymity of all those involved in the session.

Do you agree with the audio/visual statement above? *

YesNo

Information sharing for dual ASD assessments

SASHC is required to share forms and documentation with external assessors, such as ThinkWise Psychology/Tim Dansie Psychology, as required for the purpose of conducting dual ASD assessments.

By checking 'yes' inthe appropriate box below, you acknowledge your decision regarding the sharing of relevant information to facilitate comprehensive evaluations and support for individuals undergoing ASD assessments.

Please be aware that should you chose not to allow information to be shared, a dual ASD assessment cannot be undertaken.

Do you agree with the information sharing for dual ASD assessment statement above? *

YesNoSingle ASD assessment (not applicable)

Cancellations/Rescheduled Appointments

Preparation for an ASD assessment is carried out well before the assessment day. Therefore, a non-refundable deposit of $300 is required at the time of booking. If the assessment is cancelled or rescheduled within 7 working days of the scheduled assessment date, the deposit will be forfeited.

We strive to send reminders for upcoming appointments; however, it is your responsibility to inform us if you are unable to attend in a timely manner.

Fees and Rebates

Fees Payable

If you are a Medicare client, you are required to pay the fee in full on the day of the appointment. Your rebate will be processed through MEDICARE and will be deposited into your nominated bank account within 24 hours of service if you are registered with MEDICARE for rebates.
All private health rebates will be made through HICAPS on the day of the appointment.
If you are an NDIS participant and the NDIA does not pay any account associated with the service provided you will be legally responsible to pay SASHC for the unpaid accounts.
Reports of any type will not be released without prior payment.

Consent

I (please print name) *

have read, understood and agree to the above conditions, and as the authorised person, agree to the provision of services by SASHC.

Signature *

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Date *