Asperger Syndrome Support: initial interview
advertisement
Initial Interview for Students with Autism/Asperger’s Syndrome Date of interview: ………………………………………………… Referral source (disability consultant/self/parent/academic staff): ………………………………………………………………………………………….. Consultant’s Name: …………….....................…………………………………….. Student’s name: …………………………………………………....................….. Date of birth: ………………………………………………………………………….. Age at interview:……………………………………………………………………… Program at Humber.......................:………………………………………………… Campus:…………………………………………………………………………….. Program Coordinator:…………..………………………………………………… Address while at school: ……………………………....................................……. ………………………………………………………………………………………….. ………………………………………………………………………………………….. Home address if different:…………………………………………………………… ………………………………………………………………………………………….. Email: ……………………………………………………………………….............. Telephone: ………………………………………………………………………….. Age at diagnosis of Autism/Asperger syndrome: ……………………………….... What was your reaction to getting a diagnosis of Asperger syndrome? ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… Associated problems (e.g. ADHD – aggression – depression – anxiety – Tourette syndrome – dyspraxia – eating issues – digestive problems– OCD – drug/alcohol abuse – mood swings): …………………………………………………………………………………………. ………………………………………………………………………………………….. Previous support (mentoring/support groups/strategies) ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. Can you describe your time at secondary school, e.g. favourite subjects – teachers – relationships with peers – extra-curricular interests? ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… 2 What support did you receive at school that you found helpful? ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… What aspects of school life did you find most difficult and challenging? ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… Did you receive any support or advice to prepare you for the transition from school to college? ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… Were you comfortable about disclosing your diagnosis to others at school? (peers/teachers) ……………………………………………………………………………………… ……………………………………………………………………………………… Are you comfortable about disclosing your diagnosis to others at college? (peers/academic staff/disability support staff/administrative staff/staff in hall of residence) 3 ……………………………………………………………………………………… ……………………………………………………………………………………… What are your particular interests or hobbies? ………………………………………………………………………………………… …………………………………………………………………………………………. ………………………………………………………………………………………… How do you spend your leisure time? ………………………………………………………………………………………… ………………………………………………………………………………………… Are you able to share your interests with others? (friends/clubs/societies/email)? ………………………………………………………………………………………… ………………………………………………………………………………………… …………………………………………………………………………………………. Do you avoid social situations? ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… 4 Do you have difficulty in making or keeping friends? ………………………………………………………………………………………… ………………………………………………………………………………………… Do you lose your temper easily or become upset or distressed when things go wrong? What sorts of experiences are likely to distress you? ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… Do you ever feel you are being bullied or manipulated by others? ………………………………………………………………………………………… ………………………………………………………………………………………… …………………………………………………………………………………………. ………………………………………………………………………………………….. If something upsets you how do you usually react? ………………………………………………………………………………………… ………………………………………………………………………………………… …………………………………………………………………………………………. 5 How do you feel about having conversations with people on the phone? ………………………………………………………………………………………… ………………………………………………………………………………………… Do you have difficulties with concentration? Can you only concentrate on one thing at a time? ………………………………………………………………………………………… ………………………………………………………………………………………… How do you intend on concentrating in lessons that you aren’t really interested in? ………………………………………………………………………………………… ………………………………………………………………………………………… Are you easily distracted or upset by noise, lights, smells or textures in your immediate environment? ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… …………………………………………………………………………………………. Do you have a restricted diet? Are there certain tastes or textures that you avoid eating? 6 ………………………………………………………………………………………… ………………………………………………………………………………………… …………………………………………………………………………………………. How comfortable are you to use public washrooms? …………………………………………………………………………………………. Are you upset by close proximity of others or crowded environments? ………………………………………………………………………………………….. ………………………………………………………………………………………….. How do you react to changes to your daily routines or lifestyle? ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… Do you like your day to be predictable? Does it help you to follow a detailed timetable? ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… If you are living in residence, are you happy with your accommodation? Are there any specific changes to your living arrangements that you would like to make? 7 ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… Where do you usually have your meals during term time? Do you ever avoid meals or forget to eat or drink? ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… Are you able to manage your finances without help? ………………………………………………………………………………………… ………………………………………………………………………………………… Have you developed a routine for managing your personal life (washing, shopping, cooking, cleaning, etc.) or do you find these aspects of living away from home difficult? ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. Do you have difficulty finding your way around the college or using public transport? ………………………………………………………………………………………… 8 ………………………………………………………………………………………… ………………………………………………………………………………………… What particular skills and strengths do you think you have? ………………………………………………………………………………………… ………………………………………………………………………………………… Do you have a good memory? What sort of things do you remember? ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… Do you find it difficult to ask others for help or guidance when you have a problem? ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………….. Are you happy with your choice of course? Are there any aspects of the course that are causing you problems? ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… 9 Describe your learning experiences in seminars, tutorials and lectures. Which teaching methods suit you best? ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… Do you feel you can take an active part in group discussions? ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… Do you think that regular support from a staff member/consultant would help you to get more out of your college education? ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… Are there any specific aids that would help you with your course (e.g. laptop computer, voice recorder, electronic diary, timers, etc.)? ………………………………………………………………………………………… ………………………………………………………………………………………… Do you manage to complete your assignments on time? ………………………………………………………………………………………… 10 ………………………………………………………………………………………… Do you understand and learn from the feedback (both verbal and written) that you receive from your tutors? ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… Do you have any specific concerns about exams such as excessive anxiety, poor handwriting, time management or disturbing or being disturbed by others? ………………………………………………………………………………………… ………………………………………………………………………………………… Are you aware of the student counselling service and the Bursary for Students with Disabilities? ………………………………………………………………………………………… ………………………………………………………………………………………… Is there anything else that you would like to mention? ………………………………………………………………………………………… Student’s signature ………………………………………………. Interviewer’s signature …………………………………………... 11
