Initial Parent Questionnaire
Please Return to our Office Before or at Your Intake
Autism Outreach, Inc.
455 SpringPark Place
Suite 200A
Herndon, VA 20170
Phone: 703-689-0019
www.autismoutreach.org
1
Contact Information
Child’s Name
Child’s DOB
Mother’s Name
Father’s Name
Address
Cell Phone
Home Phone
Email
What is the best
way to contact
you?
Photo of Your Child
2
Information
Diagnosis
Date of Diagnosis
Child’s Current School
Current
Grade
Teacher(s)
Doctor(s)
Name
Location
Contact Info
Current Therapies
Treatment
Provider
Dates/ Duration
Therapists
Name
Service Provided
Contact Info
3
Family History
Birth history (trauma,
complications,
problems)
Siblings:
Name
Age
Relationship (bio, step, adopted)
Therapy or counseling
history (when, name
of person, title,
diagnosis, treatment
method, length of
treatment, outcome)
Family history of
psychiatric problems
including relatives
Custody and visitation
concerns
Please describe your
child’s hobbies,
interest and talents
Please describe your
child’s strength,
abilities and positive
qualities
Please describe your
child’s activity level
4
Developmental History
Milestone
Age
Comments
Crawling
Sitting
Walking
Speech
Sleeping through the
night
Eating solid foods
Health
Yes/No Description
Is your child currently on
any medications? If so,
please list name and
description?
Does your child have
seizures? If so, how often
and what is the emergency
care plan?
Is your child on any special
diet? If so, please
describe?
Is your child allergic to any
foods? If so, please list and
describe reaction?
Please describe your
child’s eating habits:
5
Self Help Skills
Skill
Age
Amount of Independence
Toileting
Feeding
Grooming
Dressing
Behaviors
Behavior
Severity
Occurrence
Duration
6
Social Behavior
If Yes, please explain
Does your child have
trouble separating?
Yes
No
Does your child turn
to you for comfort?
Yes
No
Does your child give
you eye contact?
Yes
No
Does your child
respond to his/her
name? How?
Does your child greet
you? How?
Yes
No
Yes
No
Does your child show
interest in other
people? How?
Does your child draw
attention to
something he/she is
interested in (or
accomplished)?
How?
Yes
No
Yes
No
7
Social Navigation Skills
If Yes, please explain
Does your child initiate social
interaction with peers? How?
Is your child aware of how
he/she is perceived by
others?
Does your child observe and
process social cues?
Does your child participate in
group activities effectively?
Does your child interpret the
thoughts and emotions of
others?
Does your child ask for help
when he/she needs it?
Does your child use eye
contact and non-verbal
language to understand
others’ messages?
Does your child correctly
interpret figurative and/or
abstract language
Does your child recognize
and solve his/her problems?
Does your child react
appropriately to the size
problems he/she is faced
with?
Is your child able to focus on
larger concepts rather than
just details?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
8
Language Levels
How does your child
communicate his/her
wants/needs?
How many
words/signs does your
child have?
Is your child’s
language understood
by others?
Imitation Skills
Does your child imitate
your actions?
Does your child imitate
the actions of others
(peers)?
Will your child imitate
on command, the first
time requested?
Receptive Skills
Does your child follow
simple one step
directions?
Does your child follow
simple two-step
directions?
Does your child follow
novel directions?
Does your child
identify items you
request?
9
Expressive Skills
Does your child
verbally label his
wants/needs?
Does your child
verbally label items
you request?
Does your child
verbally comment
about things in his/her
environment?
Does your child ask
questions?
Educational Background
What type of program
does your child
attend?
How long has your
child been in this
program?
Please describe the
program.
10
Program Expectations
What are your goals
and expectations for
your child in our
program?
What types of
program are you
interested in (1-1
therapy, social skills,
social group, camp
etc.)?
When do you plan to
start this program?
How many hours a
week?
May we ask who
referred you to us or
how you heard about
us?
11
Questions for us
Additional Information
Please list any other additional information you would like to include about your
child:
**Please make sure to include all evaluations, assessments, IEPs, etc.
_______________________________________
Name of person(s) completing this questionnaire
______________
Date
12