Saturday, August 19, 2017

Autism Support UK Initial Assessment

STRICTLY PRIVATE AND CONFIDENTIAL

Basic Information

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Please let us know your name.
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Family Information

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Contact Information

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Home Address

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Medical Information

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Self-help Skills

What is your child’s current independence level at each of the following



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Behaviour Assessment

Does your child ever display any of the following behaviours


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If you answered 'Yes' to Non-compliance please answer the following

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If you answered 'Yes' to Aggression please answer the following

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If you answered 'Yes' to Running Away please answer the following

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If you answered 'Yes' to Other Challenging Behaviour please answer the following

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If you answered 'Yes' to Tantrums please answer the following

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Other factors which impacts the day

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Does your child do any of the following?
If so, explain the behaviour and the approximate frequency.

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Social Behaviour

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Please indicate from the list below ‘how‘ your child communicates to obtain the communicative outcomes.

Please select one or more to answer below:

  • Complex Speech (sentences),
  • Multiple word phrases,
  • One word utterances,
  • Echolalia,
  • Other vocalisations,
  • Complex signing,
  • Single signs,
  • Pointing, leading
  • Shakes head,
  • Grab/ reaches,
  • Gives objects,
  • Increased movements,
  • Moves close to you,
  • Moves away or leaves,
  • Fixed gaze,
  • Self-injury,
  • Other

Communicative outcomes:

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Receptive Understanding

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Expressive language

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What is important to and for your child

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Thank you for taking time to fill out this The Autism Support UK Initial Assessment form.
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