Autism Assessment Intake Form Child's Name * First Name Last Name Date of Birth MM DD YYYY Parent(s) Name First Name Last Name Are parents together? Separated? If separated, please indicate whether both parents agree to this assessment. Together Separated Both parents agree to this assessment. Best phone number to reach you Country (###) ### #### OK to leave voicemail? Yes No Email Is it OK to email? Yes No What are the main areas of concern for your child and how long have you had these concerns for? Some examples might include socialization difficulties (e.g., difficulties with playing with others, difficulties with maintaining a back and forth conversation), unique/intense interests, sensory differences (e.g., dislike of specific sounds or textures), and picky eating. How old was your child when you first became concerned about these behaviours? Is your child's family doctor/psychologist concerned about autism specifically? What questions are you hoping to have answered through this assessment? Are you specifically looking for an autism assessment or you don’t know yet? Has your child received any previous assessments? If so, please state what types (e.g., speech, psychoeducational, occupational, etc). Is there a particular psychologist that you are hoping to work with? Any mental health challenges or stressors we should be aware of? What grade is your child in and do they have an IEP? Thank you! Our office manager will be in touch within the next week to take you through the next steps.
