Intake Questionnaire | Autism Intake HiddenNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.About YouYour Name(Required) First Last Email What pronouns do you prefer? He/Him She/Her They/Them Please describe your goals for coming in today for an evaluation(Required)What specific Autism symptoms would you like us to know about?(Required)What was your score on the Autism Quotient?(Required) What, if any, additional symptoms would you us to know about you?Please check any of the following you have experienced in the past six months(Required) Difficulty making friends Difficulty keeping friends Difficulty understanding social cues Feeling overwhelmed by social situations Preferring isolation Fatigue and low energy Low self-esteem Depressed mood Anxiety Overwhelmed by noise Sensitive to textures Sensitive to taste of food Sensitive to touch Strong need for routines Dislikes sponteneity Repetitive behaviors that calm you (i.e., rocking, pacing, hair pulling, skin-picking, etc.) How do your symptoms impact home or work?(Required)Have you seen a mental health professional before? If so, how did you feel about it?Is there a history of Autism, ADHD or mental health issues in your family?(Required)Do you have any medical conditions?(Required) Δ Related Posts Our ServicesADHD ADD NYCMiddle School: Your Role in Your Child’s SchoolingVideo Games and ADHD Do You Have Adult ADD?4 Tips for Parents of Kids Who Have ADHDADHD Awareness MonthPsychologist or Psychiatrist: What’s the Difference?
