Autism Survey

Question Title

* 1. How old is your child on the autism spectrum?

Question Title

* 2. What is your biggest challenge with your child on the spectrum?

Sleep

Eating

Temper tantrums/ meltdowns

Sensory issues: seeking and avoiding

Aggression

Other (please specify)

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* 3. How verbal is your child on the spectrum?

Not talking

Able to say some words

Only close friends and family can understand what child is saying

Speaking in short sentences and phrases

Very verbal

Other (please specify)

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* 4. What concerns you most about your child’s social interactions?

Prefers to play by him/her self

Only engages in parallel play with same age peers

Teasing/ bullying

Often gets lost in social situations

Engages in negative attention seeking behavior

Aggressive toward peers

Other (please specify)

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* 5. What type of classroom setting is your child in?

General education without one-on-one aide

General education with one-on-one aide

Special day class

Day treatment program

Non-public school

Home School

Other (please specify)

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* 6. What are your biggest concerns for your child at school?

Difficulty with transitions

Often off task or unfocused

Needs prompting to complete tasks

Becomes frustrated easily

Wants to do things his/her way rather than what is expected

Other (please specify)

Question Title

* 7. Would it be okay if I connect with you around your answers and give you some free support? If yes, please provide contact information below.

Name

City/Town

State/Province

Phone Number