Care Giver Interview - Potential ASD

Care Giver Interview - Potential ASD

Name: ______DOB:______

Informant: ______Date: ______

Interviewer: ______

Chief concerns expressed by care giver at the time of interview are as follows:

Past acuity screenings for vision and hearing reported as:
Within Normal Limits Date(s): ______
Abnormal Date(s):______

First concerns noted at what age? ______

Current developmental status is reported care giver as follows:

Areas of Functional Impairment
Social
School/Day Care
Home
Community
Communication

Motor
No reported concerns
Poor coordination, clumsy
Toe walking
Fine motor difficulty
General delay

Adaptive
No reported concerns
Inconsistent response to name
Inconsistent response to directions
Toilet training
Awareness of safety concerns
Personal care (other than toileting)
Verbal Communication

No reported concerns
Delayed Acquisition
Current Skills Delayed
Atypical speech only (echoing, scripting)
Spontaneous speech w/o communicative intent
Spontaneous speech limited to requesting, expression of needs/wants
Spontaneous speech not limited to requesting, expression of needs/wants
Verbalizes to be friendly, express interest in others
Difficulty with conversational turn taking
Difficulty engaging in sustained back and forth conversation

Non-Verbal Communicative Behavior
No reported concerns
Abnormal eye contact
Limited range of facial expressions
Absent or limited gestures

Behavior

No reported concerns
Problems at Home
Problems at School
Problems at Day Care/ After School
Tantrums (Specify: severity, frequency)
Self-injurious behaviors (Specify)
Oppositional/Defiant
Argumentative
Play
No reported concerns
Disinterest in toys
Lack of normal, varied imaginative play
Repetitive routines/rituals
Preoccupation with parts of objects (e.g., wheels on toy)

Social

No reported concerns

Isolation
Withdrawn, aloof, avoids contact with others
Content in Solitary Play
Parallel play alongside, but not with peers
Difficulty establishing friendships

Self Absorption
Described as "in own world" (e.g. talks to self, engages in self-stimulatory behavior)
Oblivious or unresponsive to presence of others

Reciprocal Interaction
Limited sharing or showing (objects or experiences, also interests, emotions & affect)
Limited eye contact or social smiling
Needs prompting to make eye contact
Excessively rigid peer play or interactional routines
Enjoys physical play (e.g., tickling) but won't engage in social or turn taking games
Reduced frequency of initiating social interactions
Reduced frequency and/or quality of social responding

Social Understanding/Skills/Motivation

Lack of interest in peers
Does not appropriately initiate or sustain peer interaction
Difficulties in developing, maintaining relationships
Trouble understanding social cues/comments, reading faces/body language
Wants friends but trouble making or keeping
Problems adjusting behavior to different social contexts
Socially Discrimination

Inappropriately talks to or hugs strangers
Developmentally inappropriate absence of stranger and/or separation anxiety
Invades personal space (gets too close to or touches others)

Restricted, Repetitive Patterns of Behavior, Interests or Activities
No reported concerns
Stereotyped motor movements
Insistence on Sameness
Inflexible adherence to routine
Difficulty with transitions (one activity to another)
Rituals in verbal or nonverbal behavior
Extreme distress w/ small changes
Rigid thinking patterns
Rigid behavior patterns
Restricted, fixated interests (abnormal in intensity or focus)
Unusual attachments to objects
Unusual or extreme preoccupations/fixations
Perseverations
Narrow, circumscribed interests
Unusual sensory reactivity or interests
No reported concerns
Apparent indifference to pain/temperature
Bothered by specific sounds or textures
Excessive smelling or touching of objects
Prolonged visual inspection or fascination with light/movements
Community Services and Education
In School Not in School
Current Grade:
School:
County:
School Records:
Not applicable
Unavailable for review and requested
Reviewed
Services Received in Past:
Babies Can’t Wait
Private Therapies
Special Education
Private School/Program
ABA
Social Skills Group
Special Education

Currently Receiving:
Babies Can’t Wait
Private Therapies
Private School/Program
ABA
Social Skills Group
Special Education