ASD ADULT SOCIAL CONTACT QUESTIONNAIRE

Patient Details

Surname of person being assessed *

Given Name of person being assessed *

Gender

MaleFemaleOther

If other, please list preferred pronoun

Details of Social Contact

Name of Person Completing this Form *

Relationship to person being assessed

If spouse / friend, please state duration of relationship

Mobile Phone *

E-mail Address *

Address

Street address

City

State

Postcode

Social & Emotional Reciprocity

How would you describe the individual's social skills presently (do they seek to engage with others or do they prefer to be on their own, etc.)?

Does the individual find it difficult following social conventions such as making small talk, joking? Please provide some examples

Does the individual seek to share their interests with others? If so, how do they go about doing this?

Does the individual tend to share their experiences such as joy from receiving a gift or achieving success at work? Please explain

Is the individual able to initiate and sustain a two way conversation for a prolonged period of time? Please provide some examples. (E.g. Do they focus on particular preferred topics? Do they listen to what others have to say?, Are they able to have a back and forth chat about a variety of topics?, Do they tend to speak out of context)? Please describe

In your opinion, does the individual struggle to respond to physical contact and affection (with their spouse/partner or other close family members?) Please explain

Does the individual have unusual emotional responses? How do they usually respond when upset (how often do they tend to get upset and do they often seek consolation from others, and if yes how much consolation do they tend to require? Please explain

Does the individual often understand the reason others are upset? Do the individual's emotional reactions seem appropriate? Does the individual discuss the reason they are upset with those close to them? Please explain

Does the individual always recognise when another person is upset, hurt or unwell? How do they typically react in these situations?

Does the individual tend to offer others help without being asked to? Do they tend to accept help from others? Please describe

Non-Verbal Responses

What do you think about the individual's use of eye contact? Do they tend to look at the person speaking to them, or do they look away?

Does the individual tend to vary their facial expressions when communicating? Do they express a range of expressions e.g. confused, stressed, engaged? Please describe

Does the individual tend to use a range of body gestures to communicate (e.g. using hands to imitate opening a door or using hands to explain an action)? Do you feel the individual's use of gestures are appropriate to the social context? Please describe

Does the individual understand how to use their body to communicate e.g. turning themselves towards another person when speaking to them, allowing for personal space? Please describe

Is the idividual able to recognise and interpret non-verbal behaviours of others such as facial expression and body language (e.g. what does it mean when others cross their arms)? Please provide examples

What do you think about the quality of the individual's speech? Do they speak in a monotonous voice? Do they vary their volume? Have you known them to speak in an unusual accent? Please explain

Maintenance of Relationships

Is the individual able to 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 the individual be aware if they had offended or upset others? Do you feel they have a good understand of the consequences of their behaviour on others e.g. the impact it might have on others such as their spouse/family members?

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 being teased? Are they able to take a joke? Please explain

Does the individual ever make socially inappropriate statements or ask socially inappropriate questions? Please describe

Is the individual able to make and keep friends? Do they have a preferred group of like-minded people they engage with? Describe their friendships and how they interact with others

Does the individual tend to attend social events with friends/peers? Please explain

Would you consider the individual an imaginative person? Please explain

Stereotypical Behaviours

Does the individual present with an unsual speech pattern? Do they tend to have a formal way of speaking? Do they prefer to use certain phrases/words regularly? If so, please provide some examples.

Does the individual carry out any unusual motor movements such as rocking or flapping, finger flicking, body posturing, grimacing, foot to foot rocking? Please provide examples

Does the individual tend to hoard items or have any unusual collections e.g. collecting chocolate wrappers or rocks)? Please provide examples

Routines

How does the individual respond to big changes to their routine e.g. going away on a trip, moving house etc.? Please explain

How does the individual respond to smaller changes (others moving furniture around, close family members changing their hair to a different style, ending a game before it has ended, driving a different way to a familiar place, changing to a different type of clothing e.g. shorts to jeans? Please provide examples

How does the individual cope moving from one activity to another? Are they able to transition from task-to-task? Can they move on to a different task without completing the task before? Please explain

Does the individual have a strong sense of justice/injustice and right/wrong? Do they get angry and upset if people have done the wrong thing? Please explain

Restricted and Fixated Interests

Is the individual particularly attached to any unusual item e.g. a coin/card/toy that they need to have with them most times? Please explain

Does the individual fixate on certain topics of interest e.g. trains/history/sports teams? Do they consistently veer conversations to their topics of interest? Please explain

Reactivity to Sensory Input

Does the individual tend to dislike/avoid touch/hugs/cuddles? If yes, please explain

To your knowledge, does the individual have any issues with grooming routines e.g. disliking their hair being brushed or the feeling of brushing their teeth? Please explain

To your knowledge, does the individual struggle to wear certain types of clothing (e.g. tags, seams, logos, dressing for temperature such as preferring to wear jumpers all through summer?) Please explain

To your knowledge, does the individual have a high or low pain threshold e.g. feeling increased pain for small scrapes and scratches? Please provide examples

Does the individual tend to like to put things in their mouth such as pencils, fingers etc.? Please provide examples

Does the individual tend to under or over react to unexpected sounds (e.g. having to use headphones when out and about to block noise out)? Please explain

To your knowledge, does the individual tend to sniff objects/food/people? Please explain

To your knowledge, does the individual have any difficulty with certain types of food? Are they a fussy/picky eater? Do they tend to eat similar foods regularly and not vary their menu? Please explain

General

Is there anything more you would like us to know about the individual?

What would you consider to be the individual's strengths?

What do you think are the individual's biggest challenges at present? Please explain

Collection Statement

Allied Health Services

Speak Hear is required to collect and record personal information about you in order to provide quality allied health services. This may include assessing, diagnosing and providing therapy. This information is relevant to your situation, such as your name, contact information, medical history and other relevant information as part of our service provision. 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 the assessment and treatment, is kept securely. In the interest privacy, this information is only used by therapist/s and authorised Speak Hear staff . Your personal information is retained for record keeping purposes and enables therapist to provide a relevant and informed service. A more detailed description is provided in the Speak Hear “Privacy Policy”. This policy is available to you on request.

Access to client information

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

Disclosure of personal information

All personal information gathered by Speak Hear 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.

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

Consent

I (please print name) *

have read, understood and agree to the above conditions, as the authorised person completing this form.

Signature *

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Date *