Initial Consultation Form

Medical/Health

Medical History

Genetic Completed
Birth hearing screening or childhood Hearing test completed
Vision tested

ADL

Sleeping Patterns:

Problems initiating sleep
Problems maintaining sleep

Toileting:

Day trained

Eating Patterns/Food Issues:

Food selectivity
Aversion to swallowing (keeps food in mouth)
Texture issues
Gags on food
Self feeds
Independently drinks
History of check infections
Associated Therapies for eating/feeding:

Education

Individualized Education Plan:
Behavior
Peer relationships
Grades
Learning
Communication
Suspended/expelled/retained
Poor attendance

Other

Family Functioning

Are parents:

Physical Development/Motor Skills

Developmental Presentation (check all that apply):

Gross Motor Skills:

Walking/running
Jumping
Climbing
Skipping
Riding a bike
Good spatial awareness
Throwing/catching ball
Other

Fine Motor Skills:

Using utensils
Holding crayon/pencil
Turn Pages of Book
Using zippers
Folding Papers
Tying Shoelaces
Using scissors
Buttoning

COMMUNICATION AND EMOTIONAL EXPRESSION

Receptive Language Includes:

Points to pictures in a book
Follow complex instructions (e.g., multiple step, delayed)
Follows simple directions
Other

Speech/Communication Includes:

Echoes
Grunting
Labels
Leading adults to preferred items
Signs
Single words
Sounds
Two-word phrases
Short sentences
Vowel approximations
Conversations
To-and-fro/reciprocal conversation
Question and answer type
Engages in “social chat”

Peculiar speech patterns:

Immediate Echolalia
Pronoun reversal
Delayed Echolalia
Odd tone/pitch
Odd rhythm
Idiosyncratic words/phrases

Gestures:

Waving good-bye
Lift arms to be picked up
Wave arm for “come here”
Nods head for yes
Clap hands for a good job
Shrugs shoulders
Shakes head for no
Pointing
Shake finger for “no” or “bad”
Other
Picture Communication Systems

Facial and emotional expression:

Attempts to share emotions with others:

How often?
How?

Offers comfort to others:

How often?
How?

SOCIAL BEHAVIOR

Eye contact occurs:
Eye contact is geared towards:
When name is called:
When someone enters the room:
Responds to approaches of strangers by:
Responds to someone smiling by:
Expresses interest in items to others by:
Shares things:
Has friends his own age:
Expresses interest in other children/peers by:
Participates in social games:
Examples:
Has been observed to imitate others’ actions:
Examples
Engages in pretend play:
Examples

COMPULSIONS/RITUALS/OTHER BEHAVIOR:

Repetitive Activities:

If interrupted:

Routines:

If interrupted:
Repetitive motor movements (check all that apply):
Preoccupation with certain:
Activity level:

BEHAVIOR

Maladaptive Behavior(check all that apply):

Noncompliance
Tantrums or loses temper easily
Verbal abuse/argues with others
Resentful or vindictive
Aggression
Disruption
Attentional deficits
Self-stimulation
Pica
Property destruction
Stealing
Lying/blaming others for their mistakes
Fire setting
Running away
Self-injury
Somatic complaints
Tics
Hair-pulling
Phobias

Social/Communication (check all that apply):

Inappropriate sexual behavior
Inappropriate affection toward others
Social withdrawal
Social skills deficits
Depression
Communication deficits
Echolalia
Nonsensical speech
Unresponsiveness to environment
Hyper/Hyposensitive to environment
Insistence on sameness
Lack of appropriate play skills
Separation anxiety

Psychosocial Impact:

Restricted activities with the client
Unable to run errands
Unable to attend church/mosque/religious events
Unable to travel
Unable to go out to restaurants
Restricted activities of other siblings or family members
Change in work schedule
Modifications to the home
Special locks
Rearranged furniture
Gates on stairs
Plexiglass on windows
Removal of items around the house