Find a group
Member Login
About Us
About PlayAble
The Framework
Our Partners
For Families
For Professionals
Contact Us
News
Menu
About Us
About PlayAble
The Framework
Our Partners
For Families
For Professionals
Contact Us
News
Parent Questionnaire
Please complete the Parent Questionnaire below:
Step 1 of 13
7%
Family
Enrolled Child's Name
Mother's Name
Father's Name
Guardian's Name (if different from parents)
Is the child adopted?
Yes
No
Relationship Status of Parents
In a relationship
Separated
Divorced
Does the child have any siblings?
Yes
No
Siblings
Name
Age
Who lives with the child?
Is there anyone in the immediate/extended family with developmental delays/disabilities?
(e.g. Autism Spectrum Disorder, Intellectual Disability, Learning Difficulties, ADHD)
Yes
No
Is there anyone in the family with mental health concerns?
(e.g. depression, anxiety, psychosis, etc.)
Pregnancy
How long was the pregnancy?
Were there complications during pregnancy?
Yes
No
Was any medication, drugs, or alcohol used during the pregnancy?
Yes
No
Were there any complications during delivery?
Yes
No
Delivery Method
Vaginal
Caesarean Section
Was the child healthy when born?
Yes
No
Health
Select all of the following that your child has had, at any time
Major illness
Major injury
Surgery
Hospitalisation
Head injury
Seizure
Ear infection
Allergy
Does the child have any other health concerns/conditions?
Yes
No
Please specify
Do you have any concerns about your child's diet?
Yes
No
What are your concerns?
Do you have any concerns about your child's sleep?
Yes
No
What are your concerns?
Has your child had a hearing test?
Yes
No
What was the result?
Has your child had a vision test?
Yes
No
What was the result?
Is your child on any medication?
Yes
No
Please list
Does your child have a medical diagnosis?
Yes
No
Please list
Development
Age at first single word/s
Age first put words together
Do you have any current speech or language concerns?
Yes
No
What are your concerns?
At what age did your child walk while holding on?
Do you have any concerns about your child's gross motor skills?
(e.g. running, kicking a ball, jumping etc.)
Yes
No
What are your concerns?
Do you have any concerns about your child's fine motor skills?
(e.g. holding a pencil, doing up buttons/fastenings, etc.)
Yes
No
What are your concerns?
Is your child toilet trained?
Yes
No
When did they become competent at using the toilet?
Do you have any concerns about your child's play or social skills?
Yes
No
What are your concerns?
Has your child ever experienced any stressful or traumatic events?
Yes
No
(e.g. death of someone close to them, domestic violence, parental separation, change of school/house, etc.)
School/Long Day Care
Name of child's school/long day care facility
How long has the child attended this school/long day care facility?
Does the child get extra support at school/long day care?
Yes
No
What support do they receive?
Do you have any concerns with school?
Yes
No
What are your concerns?
Professional Support
Please list any other professionals involved in your child's care including medical specialists, allied health professionals and social workers.
Strengths and Interests
Please list your child's strengths and interests.
Autism Spectrum Disorder Focused History
The following survey will ask questions about your child's observed behaviour around their social communication and interaction; non-verbal and verbal communication; friendships and play; routines and rituals; sensory response; and self-care. These questions are intended as prompts for you to reflect on your observations of your child and to gain insight into their behaviours. Use the text boxes to answer each question as you see fit.
Social Communication and Interaction
How does your child interact with other people?
How is your child with familiar versus unfamiliar people?
How affectionate is your child?
Does your child tend to look up when you enter the room?
Does your child try to share excitement? Do they tend to smile back?
Does your child share their toys? If so, with whom?
Does your child show or point out things of interest to them?
Does your child bring you things (books, toys etc.)?
Does your child like to give gifts?
Did your child enjoy peek-a-boo when they were younger?
Non-Verbal Communication
Does your child use/interpret a range of facial expressions?
How well does your child interpret tone of voice?
How aware is your child of appropriate personal space?
How does your child respond to smiling?
Does your child recognise your mood?
How do you get your child's attention?
How does your child respond to their name?
How does your child respond to eye contact?
What gestures does your child make use of?
(e.g. Nodding/shaking head, waving, clapping, blowing kisses, pointing (to request or show), etc.)
Does your child use a part of their body as a tool/extension of self?
(e.g. opening container)
Verbal Communication
How is your child with taking turns in conversation?
How does your child understand restricted topics?
Does your child change topics very often?
Does your child make appropriate responses in conversation?
Does your child tend to ask inappropriate or embarrassing questions?
Does your child use unusual pronunciation, inflexion, or accent?
Does your child make use of unusual language?
(e.g. echolalia (repeating language), quoting speech (e.g. from movies or cartoons), mixing up pronouns, jargon (made up words), words out of context, etc.)
Friendships and Play
Is your child interested in interacting and playing with peers?
Does your child initiate games or actively seek to join in?
How do other children respond to your child?
How does your child respond if another child approaches them?
Does your child like to play in a group?
Does your child have a best friend?
Does your child have a favourite toy?
Does your child like pretend/imaginative play?
Does your child like to play social games?
Does your child substitute objects in play?
Does your child engage in repetitive play?
Routines and Rituals
Does your child like routines?
What happens if the routine changes?
Does your child have any rituals?
(e.g. particular order to eat food)
Is your child particular about following rules?
How does your child tolerate surprises?
Sensory Response
Hearing
Is your child sensitive to loud/certain noises? Do they appear to be deaf, but are interested in specific sounds?
Taste and Smell
Does your child have food preferences? Do they sniff items, or have a strong reaction to smells?
Tactile
Does your child dislike certain touch? Do they have a preference for deep or light touch? Are they sensitive to pain or temperature?
Vision
Does your child like to look at items from different angles? Do they like details in pictures? Does your child like flapping their hands in front of their face, or flickering lights?
Vestibular
Does your child like spinning/swinging, or up and down movements?
Self Care
Does your child self-feed?
Does your child drink alone?
Does your child need assistance with dressing themselves?
Does your child sleep through the night? Are they able to self-sooth to get to sleep?
Does your child toilet themselves?
