Get to Know a Child Questionnaire

Child name: _________________ Informant(s): ________________________________ Age: _______

Date completed: __________________ Relationship to child: ______________ Gender: ________

The purpose of this questionnaire is to help me gather key information to help me better understand your child, so that I can design and implement effective strategies tailored to your childs individual need. The questionnaire will take between5-10 minutes to complete. 1. Has your child received a diagnosis for ASD? If so, what is the formal diagnosis?

2.

What are some of your childs favourite things? Tangibles (e.g. books, accessories, toys, favourite items):

Food or drinks:

Activities in public or private settings (e.g. favourite TV show, going to the park, dance class):

Social interactions (e.g. tablet/laptop, hugs, being read to, high fives):

Other (e.g. favourite person, subjects in school):

2. What are some things your child dislikes? a) What are your childs sensory preferences and dislikes? (e.g. colors, brightness, loud environments, putting on a helmet)

b)

What things/activities does your child try to avoid?

c)

What are some known triggers for your childs problem behaviour? How do you prevent difficult behaviour?

d)

What type of difficult behaviour does your child display? (e.g. rocking, tantrums, self-harm)

e)

What strategies are currently working to help prevent/cope with your childs problem behaviour?