Autistic Sign up – Rosehope Foundation

Sign up

Name

Who requires the service?

Sex

Age

Address

Previous service provider (if applicable)

What service is required?

Any assistive devices ?

When is the service needed?

Diagnosis (if known)

Has the child been formally diagnosed with Autism Spectrum Disorder (ASD)?

Are there any other diagnoses? Please specify.

Does the child have any allergies, dietary restrictions, or medical concerns we should be aware of ?

Are they on any medication? If yes, name, dosage, schedule.

What are the child’s strengths ?

What areas are more challenging ?

Does the child have any formal assessment reports (speech, speech therapy, learning, etc.) you can provide?

Preferred learning style(s):

What is the child’s current level of communication ?

Do they use any communication device (e.g. picture exchange systems, sign language, communication apps)?

How do they interact with peers? (e.g. plays alone, parallel play, interacts, shares)

Are there any specific behaviors of concern?

What triggers these behaviors, if known?

Sensory sensitivities or preferences (e.g. sensitivity to sound, light, texture, smell, crowds).

What sensory inputs are calming or preferred?

Level of independence in daily living: feeding, dressing, toileting, hygiene, etc.

What supports are needed in these areas?

Interests, Motivations & Preferences

What are the child’s interests, toys, games, etc.?

What motivates them (rewards, praise, stickers, treats, specific activities)?

Full Name

Mobile Number