Contact Info
+91 7304024558
support@autismconnect.co.in
Thane, Mumbai
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Thane, Mumbai, Maharashtra
support@autismconnect.co.in
+91 7304024558
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Autism Assessment Form
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Autism Assessment Form
Please complete the form below to receive an initial screening score and better understand your child’s developmental profile.
client
Child Name
Age (Years)
Gender
Male
Female
Date of Birth
Age (Months)
Parent / Guardian Name
Email
Section 2: Developmental History
At what age did your child reach the following developmental milestones?
Smiling
Earlier
On Time
Delayed
Not Yet
Not Sure
Combining Words
Earlier
On Time
Delayed
Not Yet
Not Sure
First Words
Earlier
On Time
Delayed
Not Yet
Not Sure
Walking
Earlier
On Time
Delayed
Not Yet
Not Sure
Section 3: Social Communication
Responds when name is called
Never
Rarely
Sometimes
Often
Makes eye contact
Never
Rarely
Sometimes
Often
Shares interests (shows objects)
Never
Rarely
Sometimes
Often
Uses gestures (pointing / waving)
Never
Rarely
Sometimes
Often
Understands simple instructions
Never
Rarely
Sometimes
Often
Engages in pretend play
Never
Rarely
Sometimes
Often
Initiates interaction with others
Never
Rarely
Sometimes
Often
Maintains age-appropriate conversation
Never
Rarely
Sometimes
Often
Section 4: Restricted & Repetitive Behaviour
Repeats words / phrases
Never
Rarely
Sometimes
Often
Hand flapping / repetitive movements
Never
Rarely
Sometimes
Often
Strong need for routine
Never
Rarely
Sometimes
Often
Upset by small changes
Never
Rarely
Sometimes
Often
Repetitive play patterns
Never
Rarely
Sometimes
Often
Highly focused interests
Never
Rarely
Sometimes
Often
Lines up objects
Never
Rarely
Sometimes
Often
Section 5: Sensory Profile
Sensitive to loud sounds
Never
Rarely
Sometimes
Often
Sensitive to bright lights
Never
Rarely
Sometimes
Often
Sensitive to touch / textures
Never
Rarely
Sometimes
Often
Seeks movement (spinning / jumping)
Never
Rarely
Sometimes
Often
Smells objects frequently
Never
Rarely
Sometimes
Often
Covers ears in noise
Never
Rarely
Sometimes
Often
Picky eating (textures)
Never
Rarely
Sometimes
Often
Seeks deep pressure (tight hugs)
Never
Rarely
Sometimes
Often
Section 6: Daily Living Skills
Toilet trained
Independent
Needs Help
Not Yet
Not Applicable
Eats independently
Independent
Needs Help
Not Yet
Not Applicable
Dresses independently
Independent
Needs Help
Not Yet
Not Applicable
Sleeps well
Independent
Needs Help
Not Yet
Not Applicable
Handles transitions
Independent
Needs Help
Not Yet
Not Applicable
Participates in school
Independent
Needs Help
Not Yet
Not Applicable
Section 7: Parent Observations
What are your child’s strengths?
What concerns you most about your child’s development?
Autism Connect
Developmental Screening Score Summary
Section 2: Development History
0
/ 12
Section 3: Social Communication
0
/ 24
Section 4: Restricted & Repetitive Behaviour
0
/ 21
Section 5: Sensory Profile
0
/ 24
Section 6: Daily Living Skills
0
/ 18
Total Screening Score
0
/ 99
Screening Concern Level
Low Concern
Important:
This is a developmental screening and observation tool. It is not a medical diagnosis and should not replace evaluation by a qualified professional.
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