My Child's Autism

My Child's Autism Report

Autism Assessment & Treatment Evaluation

Starting or Undergoing Autism treatment?

Assess your child's outcomes by filling this form before starting your treatment and then at every 4 weeks during the treatment to know how you are doing with the treatment.

You can also fill this form, twice a year, just to keep a check!

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Child's Unique ID

Full Name of the child

Full Name of the child

First

First

Last

Last

Child's Date of Birth

Child's Gender by Birth

Female

Male

Uncertain

Unknown

Child's Gender Identity

Female

Male

Transgender

OtherOther

Your Full Name (person filling this form)

Your Full Name (person filling this form)

First

First

Last

Last

Relationship with the child Relationship with the child

The child knows own name.

False

Somewhat True

True

The child responds to 'No' or 'Stop'.

False

Somewhat True

True

The child can follow some commands.

False

Somewhat True

True

The child can use one word at a time (No, Eat, Water, etc).

False

Somewhat True

True

The child can use two words at a time (Go home, Don't want, etc).

False

Somewhat True

True

The child can use three words at a time (want more milk, etc).

False

Somewhat True

True

The child knows 10 or more words.

False

Somewhat True

True

The child can use sentences with 4 or more words.

False

Somewhat True

True

The child explains what he or she wants.

False

Somewhat True

True

The child asks meaningful questions.

False

Somewhat True

True

The child's speech tends to be meaningful or relevant.

False

Somewhat True

True

The child often uses several successive sentences.

False

Somewhat True

True

The child carries on fairly good conversation.

False

Somewhat True

True

The child has normal ability to communicate for his or her age.

False

Somewhat True

True

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