Autism Spectrum Profile 0-18
Please Ö appropriate use: / Initial / Reassessment / Date: / M / M / D / D / Y / Y
Transition/Discharge
m / m / d / d / y / y / M / F
Child’s Name / DOB / Gender
CHILD/ADOLESCENT DOMAINS NEEDS
0 = No evidence of problem - No need for action / 1 = History - Watchful waiting & prevention
2 = Moderate need - action required / 3 = Severe problem/need - Immediate/intensive action required
**LIFE DOMAIN FUNCTIONING / 0 / 1 / 2 / 3
Family Functioning / / / /
Social Functioning / / / /
Temperament/Emotional
Responsiveness / / / /
Eating / / / /
Sleeping / / / /
Elimination / / / /
Parent- Youth Interaction / / / /
Academic Achievement / / / /
Academic Persistence / / / /
School Attendance / / / /
Classroom Behavior / / / /
Non Classroom Behavior / / / /
Special Education / / / /
Activities of Daily Living / / / /
Adaptation to Change / / / /
Transitions / / / /
Sexual Behavior / / / /
Autonomy / / / /
COGNITIVE FUNCTIONING / 0 / 1 / 2 / 3
Attention / / / /
Decision-making / / / /
SENSORY MOTOR FUNCTIONING 0 1 2 3
Gross Motor / / / /
Fine Motor / / / /
Coordination / / / /
Vision and Hearing / / / /
Sensory Responsiveness / / / /
COMMUNICATION / 0 / 1 / 2 / 3
Augmented Communication / / / /
Receptive Language / / / /
Expressive Language / / / /
Speech Articulation– Sound Production / / / /
Social/Pragmatic Use of Language / / / /
Gestures / / / /
**CHILD BEHAVIORAL / EMOTIONAL NEEDS
**Co-Morbidities / 0 / 1 / 2 / 3
Medical / / / /
Autism Spectrum / / / /
Intellectual / / / /
Attachment / / / /
Regulatory: Body Control/ Emotional Control / / / /
Impulsive Behavior / / / /
Oppositional Behavior (Compliance with Authority) / / / /
Depression/Anxiety / / / /
Psychosis / / / /
Adjustment to Trauma or
Traumatic Life Experiences / / / /
**MALADAPTIVE BEHAVIORS 0 1 2 3
Repetitive Behaviors / / / /
Restricted Interests / / / /
Aggression / / / /
Self -Injurious Behavior / / / /
Exploitation / / / /
Flight Risk / / / /
Suicide / / / /
PARENT/CAREGIVER NEEDS AND STRENGTHS
0 / 1 / 2 / 3
Language / / / /
Cultural Stress / / / /
Physical/Behavioral Health / / / /
Family Stress / / / /
Parental Responsiveness / / / /
Organization / / / /
Residential Stability / / / /
Financial Resources / / / /
Natural Supports / / / /
Caregiver Resourcefulness / / / /
Transportation / / / /
Safety / / / /
Involvement with Care / / / /
Knowledge of Child/Adolescent
Needs/Strengths / / / /
Ability to Listen / / / /
Ability to Communicate / / / /
Understanding of Impact of Own Behavior on Child/Adolescent / / / /
Knowledge of Rights &
Responsibilities / / / /
Knowledge of Service Options / / / /
STRENGTHS
0 = Centerpiece strength / 1 = Useful strength
2 = Identified strength / 3 = No strength identified
CHILD/ADOLESCENT STRENGTHS 0 1 2 3
Exploration / / / /
Persistence / / / /
Creativity/Imagination / / / /
Solitary Playfulness / / / /
Playfulness with Others / / / /
Talents/Interests / / / /
Self -Expression / / / /
Resiliency / / / /
Other______/ / / /
ENVIRONMENTAL STRENGTHS 0 1 2 3
Family Strengths / / / /
Interpersonal / / / /
Spiritual/Religious / / / /
Community Involvement / / / /
Youth Involvement with Care / / / /
Resourcefulness / / / /
**Must have at least one score of (2) or higher in each of the two highlighted sections above: “Life Domain Functioning” AND “Child Behavioral / Emotional Needs”.
Revised November 2013
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