Autism Spectrum Evaluation Clinic: Instructions and Checklist

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2300 Menaul Blvd. NE Albuquerque, NM 87107 505.272.3000 fax:505.272.2014 http://www.cdd.unm.

1 2300 Menaul Blvd. NE Albuquerque, NM fax: Autism Spectrum Evaluatin Clinic: Instructins and Checklist Please keep this checklist fr yur recrds Thank yu fr cntacting the Center fr Develpment and Disability Autism Spectrum Evaluatin Clinic. Our prgram prvides cmprehensive, team evaluatins fr Autism Spectrum Disrder and ther develpmental disabilities fr children three years and lder. Please prvide the fllwing infrmatin t prepare the team fr yur child s evaluatin. CDD-UNMMG cnsent frms must be signed by the client s legal guardian. CDD Child Infrmatin Frm (3 pages) Autism Spectrum Evaluatin Clinic-Child Infrmatin Addendum (4 pages) CDD Cnsent t Treat frm signed by legal guardian Patient Registratin frm including insurance infrmatin Race and Ethnicity frm signed by legal guardian Teacher Questinnaire Cpies f any previus develpmental r medical reprts Cpies f schl recrds, including any special educatin evaluatins r current Individualized Educatinal Prgram (IEP) reprts. If yu wuld like ur staff t request recrds, please cmplete ne Authrizatin t Request Health Infrmatin frm fr each schl r agency. Yur child will be added t ur waiting list when the packet is received. We will send yu a cnfirmatin letter, with an estimate f when yu may expect t be scheduled. Please nte, that currently ur waiting list is 18 t 24 mnths. Fax r mail cmpleted packet t: Center fr Develpment and Disability Clinical Services - Autism 2300 Menaul Blvd, NE. Albuquerque, NM Fax# Center fr Develpment & Disability at University f New Mexic 2300 Menaul NE Albuquerque, NM Phne Fax University Center fr Excellence in Develpmental Disabilities Educatin, Research and Service

2 2300 Menaul Blvd. NE Albuquerque, NM fax: INTAKE INFORMATION Child Infrmatin Please cmplete all sectins Wh is cmpleting this frm? Name and relatinship t child Tday s date: W h is referring? Referrer s phne: CHILD'S INFORMATION Name and relatinship t child Name: Date f birth: Sex: M F Primary language: Other languages: PEDIATRICIAN / PRIMARY CARE PROVIDER RR Name: Phne: Fax: Address: PARENTS/CAREGIVERS Are the Parents the legal guardians fr this child? Yes N 1. Name: Relatinship: address: Mailing address: Phnes: / Primary Other Legal Guardians, Fster Parents r Other Caregivers: 1. Name: Relatinship: address: Mailing address: Phnes: / Primary Other 2. Name: Relatinship: address: Mailing address: Phnes: / Primary Other 2. Name: Relatinship: address: Mailing address: Phnes: / Primary Other Is the Children, Yuth and Families Department (CYFD), r ther prtective service agency, invlved with the child r family? Yes N If yes, please prvide the CYFD Scial Wrker r cntact: Name: Phne: Fax:

3 Child's Name: MRN: Wh lives in the hme with the child? Name Age Relatinship t Child Primary Language If English is nt the native language fr yurself r yur child, will an interpreter be needed fr the evaluatin? Yes N If yes, what language? SERVICE PROVIDER INFORMATION Is the child currently in interventin services? (Fr example: early interventin, schl, ther therapy services, etc.) Yes N Please prvide the fllwing infrmatin regarding current interventin services: Therapist Name Agency/Schl Phne Develpmental Specialist Speech Language Pathlgist Occupatinal Therapist Physical Therapist Scial Wrker/Cunselr Hearing Specialist Special Educatin Visin Specialist Other: Other: CONCERNS / QUESTIONS Check all bxes belw that best describe the nature f yur cncern(s): Accidents / Injuries Epilepsy / Seizures Prenatal Expsures Allergies Family Stressrs Sensry / Regulatin Asthma Feeding / Nutritin Sleep Attentin Hearing Special Equipment Autism Spectrum Disrder Learning / Thinking Speech / Language Behaviral Difficulties Medical / Health Visin Crdinatin / Balance Mtr (Use f arms/legs) Other: Ear Infectins Premature / Cmplex Birth Other: CDD Child Infrmatin Frm Revised 4/2015 Page 2 f 3

4 Child's Name: MRN: Please explain yur cncerns r questins: What d yu hpe t gain frm this evaluatin? What des the child d well? What activities des the child enjy? MEDICAL/DEVELOPMENTAL INFORMATION When was child's mst recent hearing screening/test? Results? Pass Fail When was child's mst recent visin screening/test? Results? Pass Fail Des the child have medical, behaviral, and/r develpmental diagnses? (Fr example: Fragile X, ADHD, seizure disrder, Autism Spectrum Disrder, etc.): Yes N If yes, please list: Des the child take medicatin? Yes N If yes, please list: When did the child first d the fllwing: Rlled ver Sat withut help Crawled n hands and knees Walked withut help Said single wrds Put tw r mre wrds tgether (e.g., green car ) Talked in shrt sentences (e.g., Daddy has a green car ) Tilet trained (during the day) Tilet trained (vernight) Age Nt Yet Nt Sure Did the child ever lse any f the abve skills? Yes N If yes, please describe: Please feel free t attach any additinal infrmatin that yu wuld like t prvide. CDD Child Infrmatin Frm Revised 4/2015 Page 3 f 3

5 2300 Menaul Blvd. NE Albuquerque, NM fax: P Child s Name: Autism Spectrum Evaluatin Clinic Child Infrmatin Addendum Please cmplete all sectins - 4 pages FAMILY MEDICAL HISTORY Is there any histry f develpmental r behaviral issues in the child s immediate family? Please check all that apply. Autism Spectrum Disrder Mther Father Sibling Grandparent Other (Aunts, Uncles, Cusins) Language Prblems Learning Prblems Attentin Prblems Other Develpmental Delays Genetic Cnditins Neurlgical Prblems Seizures Anxiety Depressin Alchl r Substance Abuse Other mental health issues r behavir

6 Child's Name: MRN: CHILD MEDICAL HISTORY Were there any prblems r cmplicatins during pregnancy? Yes N If yes, please explain: If the child s mther used any f the fllwing during the pregnancy, please check and describe. Vitamins r Supplements Prescriptin Medicatins Tbacc Alchl Other drugs Were there any prblems r cmplicatins during delivery? Yes N If yes, please explain: Was the child brn n time? Yes N Weeks Early Weeks Late Type f Delivery: Birth Weight: Were there any prblems, cmplicatins r hspitalizatins after birth? Yes N If yes, please explain: Please describe the child s temperment/persnality during the first few mnths: CDD Autism Spectrum Evaluatin Clinic - Child Infrmatin Addendum Revised 2/2015 Page 2 f 4

7 Child's Name: MRN: Has the child been affected by any f the fllwing? Check any that apply If yes, please nte age and explain each checked area. Hspitalizatin Cncern fr Seizures Allergies Significant Illness Injuries Medical studies r specialist cnsults Sleep cncerns Feeding/diet cncerns Other cncerns (please specify) Other cncerns (please specify) Age Cmments Please list all medical diagnses yur child has been given, with age, date, and prvider wh made the diagnsis. Diagnsis Age Date Prvider/Agency Please list any medicatins the child takes currently: CDD Autism Spectrum Evaluatin Clinic - Child Infrmatin Addendum Revised 2/2015 Page 3 f 4

8 Child's Name: MRN: Has the child been affected by any f the fllwing? Please check any that apply, and explain each checked area. Adptin Fster care Dmestic vilence Physical r sexual abuse Divrce/remarriage Drug r alchl use Serius family illness Husehld mves Other cncerns(please specify) EDUCATIONAL SERVICES Has the child ever received special educatin services in schl? Never requested/referred Denied eligibility Waiting fr evaluatin Has current IEP Had IEP in the past, nt nw When was the child last tested fr special educatin services? Date: Age: Grade: Please include cpies f previus evaluatins r treatment recrds, if available: Reprts fr any schl evaluatins Current Individualized Educatinal Prgram reprt Behaviral health assessments (e.g., psychlgy, scial wrk) Reprts frm medical specialists (e.g., genetics, neurlgy) If yu wuld like ur staff t request recrds directly frm ther prviders, schls r agencies, please cmplete and sign Authrizatin t Release Health Infrmatin frms. Please feel free t attach any additinal infrmatin that yu wuld like t prvide. CDD Autism Spectrum Evaluatin Clinic - Child Infrmatin Addendum Revised 2/2015 Page 4 f 4

and its physicians and staff (including administratin f medicatin, tests and prcedures) as deemed necessary. 2.

9 Center fr Develpment and Disability Cnsent t Treatment and Assignment f Benefits 1. I, the undersigned, hereby request and cnsent t medical treatment by the Center fr Develpment and Disability r UNM Medical Grup, Inc. and its physicians and staff (including administratin f medicatin, tests and prcedures) as deemed necessary. 2. I hereby assign and request payment directly t the Center fr Develpment and Disability and UNM Medical Grup, Inc. f any insurance r ther authrized health benefits therwise payable t me fr medical treatment rendered, and t release any infrmatin required t the insurance cmpany fr cnsideratin f payment fr services. Signature f Patient r Representative Date Printed Name f Patient r Representative Relatinship t Patient Revised: 8/2014

10 Patient Demgraphic Frm UNM MEDICAL GROUP, INC. Center fr Develpment and Disability 2300 Menaul Blvd NE Albuquerque, New Mexic, Phne: (505) Fax: (505) PATIENT INFORMATION Patient's Name (Last, First, MI): DOB: Address: Phne: City: State: Zip: Tribe: Patient's SSN: Sex: M F Race/Ethnicity: Patient's Marital Status: If Married, Name f Spuse: Patient's Emplyment Status: Occupatin: Emplyer Name: Emplyer Phne: Emplyer Address: Address: PARENT / GUARDIAN (IF PATIENT IS A MINOR) Name: Relatinship: Address: City: State: Zip: Phne: NEXT OF KIN / EMERGENCY CONTACT INFORMATION Next f Kin: Relatinship: Address: City: State: Zip: Phne: REFERRING PHYSICIAN Physician Name: Phne/Fax: Address: INSURANCE INFORMATION Is patient cvered under Medicare/Medicaid? (please circle )Ye s / N Medicare/Medicaid #: lease If cvered under Medicaid, which salud? (please circle) Mlina / BCBS / Lvelace / Presbyterian Is patient cvered under Insurance? (please circle) Yes / N If yes, please prvide If the yes, fllwing: please prvide the fllwing: (Please circle) Plicy hlder's Name: Plicy hlder's DOB: Plicy hlder's SSN: Relatinship t Patient: Insurance Cmpany: Phne: Address: Grup #: Plicy #: Plicy hlder's Emplyer: Authrizatin #: Occupatin: Emplyer Address: City: State: Zip: Telephne: Authrizatin I hereby authrize CDD r UNM Medical Grup, Inc. t release any infrmatin acquired in the curse f my evaluatin t the insurance cmpany. I understand I have the right t examine and cpy the infrmatin disclsed. I authrize payment directly t CDD r UNM Medical Grup, Inc. fr the medical benefits. Signature: CDD 06/04/12 Date:

11 Dear Patient, UNM Medical Grup Inc. wants t give yu the best, safest health care pssible! Yur answers t these questins help us make sure we meet yur needs and give the best, safest health care t all patients. Yur answers will remain private. Access t this infrmatin is very restricted. Thank yu! D yu cnsider yurself Hispanic r Latin? Yes N Dn t want t answer What is yur race? PICK ONE. American Indian r Alaska Native Asian Black r African American Native Hawaiian r ther Pacific Islander White r Angl Tw r mre races Dn t want t answer If yu d nt speak English well, yu have the right t a free interpreter. We will prvide ne fr yu. In what language d yu prefer t talk abut yur health care? PICK ONE. English Spanish Vietnamese Navaj Other: In what language d yu prefer t read abut yur health care? PICK ONE. English Spanish Vietnamese I need help with reading Nne Other: If yu are American Indian/Native American, what tribe(s) r puebl(s)? Navaj Puebl: Other: Other: What is yur religin r spirituality? Baptist Buddhist Cathlic Christian: Jehvah s Witness Jewish Latter-Day Saints/Mrmn Muslim Native Traditinal Prtestant: Other: Nne Dn t want t answer What is yur relatinship status? Single Legally married Dmestic partnership/civil unin Partnered, living tgether Partnered, nt living tgether Divrced/permanently separated Widwed/separated by death Other: Patient signature: Date: Thank yu! If yu have questins, please ask ur staff. (1) Enter data int Cerner, (2) Place reg sticker here (3) send frm t ILS

12 AUTISM SPECTRUM EVALUATION CLINIC TEACHER QUESTIONNAIRE We are evaluating ne f yur students in the Autism Spectrum Evaluatin Clinic at the University f New Mexic Center fr Develpment and Disability. Yur input and cmments are invaluable fr this prcess. The family has been requested t have this frm cmpleted prir t the child s clinic appintment. If mre than ne teacher wishes t cmplete a reprt, please feel free t xerx and send multiple cpies. Please add any additinal infrmatin that yu feel may be helpful. Child s Name: Date: Teacher: Name f Schl: Address Grade Type f Class Number f students in class (including regular and special educatin) Number f teachers and aides Hw well d yu knw this student (please circle yur respnse). Hw lng? Very well Mderately well Nt very well Des this student have an IEP? Categry f eligibility? Please list yur majr cncerns abut this student: What are this student s strengths? Hw des this student interact with the ther students in yur class? Specific questins, cncerns and/r areas yu wuld like help with this child: Thank yu fr yur time. Please return this frm directly t parents t send as part f the UNM Autism Spectrum Evaluatin Clinic intake packet.

Albuquerque, NM 87131 505-925-4455 D UNM Cardilgy Clinic McMahn 4824 McMahn Blvd NW, Suite 109 Albuquerque, NM 87114 505-925-6001 D UNM Center fr Develpment and Disability 2300 Menual Blvd NE

13 AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION Patient Name: Date f Birth: Medical Recrd #: 1. I hereby authrize (Name f Disclsing Party) (Phne/Fax f Disclsing Party) (Address, City, State, Zip f Disclsing Party) T Disclse t: D UNM Center fr Reprductive Health 1701 Mn NE, Suite 200 Albuquerque, NM D UNM Cardilgy Clinic McMahn 4824 McMahn Blvd NW, Suite 109 Albuquerque, NM D UNM Center fr Develpment and Disability 2300 Menual Blvd NE Albuquerque, NM D UNM Center fr Life 4700 Jeffersn Blvd. NE, Suite 100 Albuquerque, NM D UNM Truman Health Services 801 Encin Place NE, Bldg F Albuquerque, NM Please Fax Request t: D UNM Vein and Csmetic Center 7007 Wyming Blvd NE, Suite A-3 Albuquerque, NM D UNM Dental Camin de Salud Residency Clinic 1801 Camin de Salud, Suite 1200 Albuquerque, NM D UNM Dental Nvitski Hall 2320 Tucker NE Albuquerque, NM D UNM Dental Carrie Tingley 1127 University Blvd, NE Albuquerque, NM D UNM Dental Camin de Salud Ambulatry Surgical Center 1801 Camin de Salud, Suite 1100 Albuquerque, NM Infrmatin t be disclsed: D mst recent visit/admissin D prgress ntes D schl recrds D histry & physical exam D labratry tests D psychlgical evaluatin D initial assessment D x-ray reprts D physical therapy evaluatin D cnsultatin reprts D pathlgy reprts D speech & language evaluatin D perative reprt D ER recrd/utpatient lg D ccupatinal therapy D discharge summary D Billing D Other (please specify) Cvering the perid(s) f healthcare: frm (date) t (date) frm (date) t (date) UNMMG C107 5/3/13

14 3. I further authrize that this disclsure f health infrmatin will include infrmatin relating t (initial if applicable):. a. acquired immundeficiency syndrme (AIDS) r human immundeficiency virus (HIV) infectin, r ther sexually transmitted diseases initial b. behaviral health services/psychiatric care initial c. treatment fr alchl and/r drug abuse initial d. genetic test results and related patient infrmatin initial 4. I understand that I have a right t revke this Authrizatin at any time. I understand that if I revke this Authrizatin I must d s in writing and present my written revcatin t the Health Infrmatin Management Department. I understand that the revcatin will nt apply t infrmatin that has already been released in respnse t this authrizatin. I understand that the revcatin will nt apply t my insurance cmpany when the law prvides my insurer with the right t cntest a claim under my plicy. Unless therwise revked, this authrizatin will expire n the fllwing date, event, r cnditin:. If I fail t specify an expiratin date, event r cnditin, this authrizatin will expire in six mnths frm the date n which it was signed. 5. I understand that nce the abve infrmatin is disclsed, it may be redisclsed by the recipient and the infrmatin may nt be prtected by federal privacy laws r regulatins. 6. I understand that authrizing the disclsure f this health infrmatin is vluntary; that I can refuse t sign this Authrizatin and need nt sign this Authrizatin t btain health care treatment; and that if I authrize the disclsure f this health infrmatin, I have the right t examine and cpy the infrmatin t be disclsed. A cpy f this signed Authrizatin will be prvided t me. Signature, Patient, r legal representative (Relatinship t patient) (Date) Signature f Witness (Date) (Parent, if CPH/PFC&A patient ver 14) (Date) PROHIBITION OF REDISCLOSURE: Federal regulatins (42 CFR Part 2) and State laws (NMSA , 32A-6A-24, 24-2B-7 and ) prhibit further disclsure f mental health r alchl and/r drug abuse treatment infrmatin, and f the results f tests fr HIV/AIDS and ther sexually transmitted diseases t any persn r agency withut securing anther prper written authrizatin fr that purpse, r as therwise permitted by Federal regulatins r State laws. UNMMG C107 5/3/13

Child s Name: Date of Birth: TAKE THIS SHEET TO EVERY DOCTOR S APPOINTMENT

Child s Name: Date of Birth: TAKE THIS SHEET TO EVERY DOCTOR S APPOINTMENT Date f Birth: TAKE THIS SHEET TO EVERY DOCTOR S APPOINTMENT Prtable Medical Summary Name: Date Updated: / / Address: Phne: Mbile: E-mail: DOB: SSN: - - Allergies: Pertinent Persnal Characteristics: What