Beyond Autism — A Collaborative Approach
Beyond Autism — A Collaborative Approach

Intake Questionnaire

To better acquaint us with your child, please complete this form. Only the fields marked * are required; share as much as you can.

About your child

Medical / health

History of seizures

Educational

What services is your child receiving? (select all that apply)
Is your child able to sit at a desk and complete a task?
Is your child able to work independently?
Does your child participate in (select all that apply)
Does your child require a 1:1 aide during the school day?
Is your child receiving or has your child previously received ABA therapy?
Permission to contact this agency?

Communication

What form(s) of communication does your child use? (select all that apply)
Does your child use a different communication system at home than at school?
Does your child request desired items or activities spontaneously?
Is your child able to follow directions when asked to complete small tasks around the house (i.e. shut the door, come here, wash your hands)?

Safety

Does your child exhibit safety awareness in parking lots, near water, in the community?
Does your child exhibit safety while riding in vehicles?
Does your child have a history of elopement?
Does your child react appropriately when asked to hold their hand/arm for safety purposes?
Does your child place inedible objects in their mouth?
Choking hazard?

Behavioral

Does your child have a current Behavior Intervention Plan?
Does your child require a 1:1 aide to manage their behavioral needs?
Does your child exhibit different behaviors at school than you see in the home?
Does your child exhibit any self-injurious (towards self) or aggressive (towards others) behaviors?
Does your child exhibit disruptive/challenging behaviors with any of the following?
Noisy environments
Changes to schedule
Waiting
Taking turns
During non-preferred tasks
Being told “no,” “not now” or “later”
Limited access to preferred item(s)
Transitions
Trips to stores, barber, dentist, etc.
During mealtime
Completing the bathroom routine

Sensory

Does your child seek out (select all that apply)
Does your child have any aversions to odors, textures, sounds, eye contact, taste?

Life / functional skills

How would you describe your child’s level of independence in the following areas?
Eating / drinking
Toileting
Showering, bathing
Brushing teeth, hair
Dressing, undressing
Getting in/out of vehicle, seatbelt
Handwashing
Meal/snack prep

Play / leisure

Goals

In order of priority, please rate your goals for your child (1 = greatest, through 5 = least)

Commitment

Are you, the family, willing to work collaboratively with our team and actively participate in your child’s education?
Beyond Autism is a non-profit organization that requires participation from our families to ensure we can continue to provide a comprehensive program for all of our students. Are you able and willing to assist with our annual fundraiser in some capacity?

Documents

Please attach your child’s current IEP, MET, BIP and the most recent diagnostic evaluation(s) that will assist our team in determining if placement is appropriate for your child.

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