National Professional Development Center on Autism Spectrum Disorders
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1 National Professional Development Center on Autism Spectrum Disorders Parent and Child Information Questionnaire Thank you for taking time to complete this questionnaire. This information will help us to learn about the ways in which the programs and services provided help children and youth with ASD and their families. Please complete each section of the questionnaire and return it to us in the postage paid envelope. Today s date: Student s Initials: School Site: Parent/Family Background Information Please tell us about yourself and family. 1. Person completing this form: Biological mother Biological father Step/adoptive mother Step/adoptive father Grandparent Other (please indicate: ) 2. In what state do you currently reside? National Professional Development Center on ASD 1
2 3. What is your age? Under Over How many years of school have you completed? 5. Are you: Some high school High school graduate/ged Some community college Community college graduate Some college College graduate Completed graduate school Married Living with a partner Single/never married Separated/Divorced/Widowed National Professional Development Center on ASD 2
3 6. What is your race/ethnicity? African American Asian American Indian Latino White Biracial/Multiracial Other (please describe) I. Child Information 7. Age of child with ASD. Child Background Information 8. What is your child s date of birth? / / 9. Gender of child with ASD. National Professional Development Center on ASD 3
4 10. Please check ALL diagnoses that apply to your child: Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS) Childhood Disintegrative Disorder Other (Please specify) 11. At what age was your child diagnosed with ASD? 12. Number of other children in the home. 13. Please indicate age and gender of siblings. Sibling #1 Sibling #2 Sibling #3 Sibling #4 Age Gender Age Gender Age Gender Age Gender National Professional Development Center on ASD 4
5 14. Do any of your other children have diagnosis of ASD or other disability? Check all that applies for each child. Sibling #1 Sibling #2 Sibling #3 Sibling #4 Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS) Childhood Disintegrative Disorder Other (Please specify) Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS) Childhood Disintegrative Disorder Other (Please specify) Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS) Childhood Disintegrative Disorder Other (Please specify) Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS) Childhood Disintegrative Disorder Other (Please specify) II. School/Program 15. What type of program/school does your child currently attend? For each program/school circled, please indicate how long your child has attended this program. Home-based early intervention services Developmental day center Community-based early childhood program (e.g., preschool, child care center) Public school early childhood special education classroom Public school inclusive early childhood program Public school special education classroom (please indicate which grade) Public school general education classroom (please indicate which grade) Inclusive and special education (some time in both settings) 16. How many hours per week does your child attend this school/program? National Professional Development Center on ASD 5
6 17. What services does your child receive at school? How many hours per week? How many sessions per week? How many sessions per month? 1. Speech-language therapy 2. Occupational therapy 3. Physical therapy 4. Sensory integration therapy 5. Special education/general 6. Other: Hours per week # sessions per week # sessions per month 18. What private services does your child receive outside of school? How many hours per week? How many sessions per week? How many sessions per month? 1. Speech-language therapy 2. Occupational therapy 3. Physical therapy 4. Sensory integration therapy 5. Special education/general 6. Other: Hours per week # sessions per week # sessions per month 19. Who made the decision about your child s current placement? Check all that apply. It was decided primarily by professionals on my child s placement team. The decision was made by professionals at my child s annual IFSP/IEP meeting. My family was actively involved in the decision-making process. Other National Professional Development Center on ASD 6
7 20. What are the MAJOR reasons you use this program/school for your child? Check all that apply. No choice, only option provided. Best option available. Offers special education services or therapies. Provides an opportunity for my child to interact with typically developing peers Provides opportunities for my child to learn Location is good for our family Offers high quality staff Other 21. Of the reasons you gave, which is the most important? No choice, only option available. Best option available. Offers special education services or therapies. Provides an opportunity for my child to interact with typically developing peers Provides opportunities for my child to learn Location is good for our family Offers high quality staff Other National Professional Development Center on ASD 7
8 III. Community Inclusion 22. Does your child participate in any community groups? Yes No 23. If yes, please provide the following information: Type of Group (see chart below) # times attended per month # children involved Are typical children included? (Example) times per month 15 children YES/NO 1. YES/NO 2. YES/NO 3. YES/NO 4. YES/NO 5 YES/NO Type of Group: 1. Athletics/Parks and Recreation Activities 2. Special Olympics 3. Church Related (e.g., choir, Sunday school) 4. Music lessons 5. Scouts 6. Dance 7. Other (please specify) National Professional Development Center on ASD 8
9 IV. Medical Information 24. Has your child ever been prescribed any medications? Yes No 25. If yes, what meds has s/he been prescribed in the past 6 months? Medication Dose Frequency Currently taking Yes No Antidepressants: Wellbutrin, Celexa, Lexapro, Prozac, Paxil, Zoloft Stimulants: Ritalin, Metadate, Concerta, Dexedrine, Dextrostat, Adderall Antipsychotics: Abilify, Clorazil, Haldol, Zyprexa, Seroquel, Risperdal Mood Stabilizers: Depakote, Neurontin, Lithobid, Topamax, Tegretol Anxiolytics: Ativan, Librium, Klonopin, Valium, BuSpar Anti-Convulsants: Klonapin, Dilantin, Tegretal, Depakote, Depakene, Xanax, Niravam, Buspar, Ativan, Vivitrol, Valium Other National Professional Development Center on ASD 9
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