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Rooted Minds Psychiatry
Helping Minds Thrive
Autism Assessment Package
Autism Spectrum Disorder
Evaluation — Parent/Caregiver Forms
Evaluation — Parent/Caregiver Forms
Confidential clinical document · Complete all sections before appointment
Tab 1 — Developmental History
Instructions for caregivers: This form helps us understand your child's development from early on. There are no right or wrong answers — we are looking for patterns across different areas of development. Please type your answers directly into the form. Click Yes or No on each item.
1
Pregnancy, Birth & Early Medical History
Were there any complications during pregnancy or delivery?
e.g. infections, medications, premature birth, low birth weight, oxygen issues, NICU stay
Gestational age at birth
Birth weight
Any early medical concerns in infancy?
e.g. feeding difficulties, colic, chronic ear infections, seizures, hospitalizations
Family history of autism, ADHD, intellectual disability, anxiety, or learning differences?
2
Early Developmental Milestones
Type age achieved or "delayed / not yet"
Smiled socially
Sat independently
Crawled
Walked independently
First words
Two-word phrases
Full sentences
Toilet trained (day)
Pointed to share interest
Waved bye-bye
⚑ Clinical flag: Was there any loss or regression of skills the child had already developed? (e.g. lost words, stopped making eye contact, withdrew socially)
Did your child ever lose skills they had previously developed?
If yes — what was lost, at what age, and was it sudden or gradual?
3
Social Communication & Interaction
| Behavior / Trait | Yes | No | Notes / Age noticed |
|---|---|---|---|
| Made comfortable eye contact as an infant/toddler | Y | N | |
| Responded to their name being called | Y | N | |
| Pointed to show you things they were interested in | Y | N | |
| Brought objects just to share — not only to get help | Y | N | |
| Looked where you were pointing | Y | N | |
| Imitated actions or sounds (clapping, peek-a-boo) | Y | N | |
| Engaged in back-and-forth babbling / conversation | Y | N | |
| Showed interest in other children their age | Y | N | |
| Has/had close friendships | Y | N | |
| Understood facial expressions / emotions in others | Y | N | |
| Engaged in pretend / imaginative play | Y | N |
Describe your child's current friendships and peer relationships:
4
Language & Communication
| Behavior / Trait | Yes | No | Notes |
|---|---|---|---|
| Repeats words or phrases out of context (echolalia) | Y | N | |
| Scripts lines from TV, movies, or books | Y | N | |
| Speaks in unusual tone, pitch, or rhythm | Y | N | |
| Takes language very literally — misses sarcasm or jokes | Y | N | |
| Difficulty starting or maintaining conversation | Y | N | |
| Talks at length about one topic regardless of others' interest | Y | N | |
| Misunderstands idioms or figures of speech | Y | N | |
| Has received speech/language therapy | Y | N |
5
Restricted, Repetitive & Ritualistic Behaviors
| Behavior / Trait | Yes | No | Notes / Examples |
|---|---|---|---|
| Intense, narrow interests that dominate conversation or play | Y | N | |
| Lines up toys or objects rather than playing with them | Y | N | |
| Insists on routines or sameness (same route, same order) | Y | N | |
| Becomes very distressed by changes in routine | Y | N | |
| Repetitive body movements (rocking, hand-flapping, spinning) | Y | N | |
| Repetitive vocalizations (humming, clicking, scripting) | Y | N | |
| Preoccupied with parts of objects (wheels, lights, patterns) | Y | N | |
| Rigid thinking — difficulty accepting other perspectives | Y | N |
Describe your child's special interests in detail:
6
Sensory Sensitivities
| Sensory Area | Over-Sensitive | Under-Sensitive | Notes / Examples |
|---|---|---|---|
| Sound (noise, covers ears) | ✓ | ✓ | |
| Touch (clothing tags, textures, hugging) | ✓ | ✓ | |
| Food textures or tastes — very restricted diet | ✓ | ✓ | |
| Light (bright lights, sunlight) | ✓ | ✓ | |
| Smells | ✓ | ✓ | |
| Pain (may not react to injury, or extreme reaction) | ✓ | ✓ | |
| Movement / balance (seeks or avoids spinning, swinging) | ✓ | ✓ | |
| Crowds or busy environments | ✓ | ✓ |
7
Emotional Regulation & Behavior
| Behavior / Trait | Yes | No | Notes |
|---|---|---|---|
| Meltdowns that seem disproportionate to the trigger | Y | N | |
| Difficulty recovering from upset or transitions | Y | N | |
| "Shutdowns" — goes quiet, withdraws, stops responding | Y | N | |
| Significant anxiety, especially around social situations | Y | N | |
| Difficulty identifying or naming their own emotions | Y | N | |
| "Holds it together" at school but falls apart at home | Y | N | |
| Masks / camouflages — copies others to fit in | Y | N | |
| Appears exhausted after social events | Y | N |
8
School & Learning
Current school
Grade level
| Area | Yes | No | Notes |
|---|---|---|---|
| Has an IEP or 504 Plan | Y | N | |
| Receives special education services | Y | N | |
| Teachers have raised behavioral or social concerns | Y | N | |
| Strong in specific academic areas (e.g. math, reading) | Y | N | |
| Difficulty with group work or unstructured time | Y | N |
9
Prior Evaluations & Services
Speech / Language Therapy
Occupational Therapy
Applied Behavior Analysis (ABA)
Psychological / Neuropsychological Testing
Developmental Pediatrics Evaluation
Individual Therapy / Counseling
Social Skills Group
Psychiatry / Medication Management
Early Intervention (birth–3 program)
Physical Therapy
Previous diagnoses received (and by whom):
Current medications (name, dose, prescriber):
10
In Your Own Words
When did you first notice something was different, and what did you notice?
What does your child struggle with most right now?
What are your child's greatest strengths?
What are you hoping to learn or get from this evaluation?
Is there anything else important for us to know?
Caregiver Name (printed)
Date
By completing this form, you confirm that the information provided is accurate to the best of your knowledge and consent to its use in the clinical evaluation process.
Tab 2 — CAST Scale (Ages 4–11)
Childhood Autism Spectrum Test (CAST) — Ages 4–11 · Parent-report · 37 items
Please answer each question based on how your child usually behaves. Circle "Yes" or "No" for each item. There are no right or wrong answers. Questions 31–37 are developmental/medical screening items and are scored differently — see scoring key at the bottom.
Please answer each question based on how your child usually behaves. Circle "Yes" or "No" for each item. There are no right or wrong answers. Questions 31–37 are developmental/medical screening items and are scored differently — see scoring key at the bottom.
+
Developmental / Medical Screen (Items 31–37)
Not included in core CAST score
Thank you for completing this section. Your clinician will review your responses at your appointment.
Tab 3 — AQ-Child (Ages 4–17)
Autism Spectrum Quotient — Child Version (AQ-Child) — Ages 4–17 · Parent-report · 50 items
For each statement below, please select how strongly it applies to your child. Choose Definitely Agrees, Slightly Agrees, Slightly Disagrees, or Definitely Disagrees. Please answer based on what you observe at home, not what teachers or others say.
For each statement below, please select how strongly it applies to your child. Choose Definitely Agrees, Slightly Agrees, Slightly Disagrees, or Definitely Disagrees. Please answer based on what you observe at home, not what teachers or others say.
Thank you for completing this section. Your clinician will review your responses at your appointment.
Tab 4 — Clinician Summary
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Clinician Access Only
This section contains clinical findings and diagnostic formulation. It is not intended for patients or families. Enter your clinician PIN to continue.
Default PIN: 1234 · Change in settings