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Autism Screening Referral Form
Please fill out this form to request a screening for a student whom you suspect has characteristics of Autism. Following your submission, you will be contacted by an Autism Spectrum Disorder Assessment Team (ASDAT) member. If you have any questions, please do not hesitate to contact Tami Bryan (tbryan@hscsed.org).
Please confirm the student is currently receiving services through at least 1 of the following (1) RtI, (2) Special Education (includes any services provided by a special education teacher or related service professional - Occupational Therapist, Physical Therapist, Speech-Language, Social Work), or (3) Behavioral supports which have been implemented and documented - If no, please go back to your RtI/intervention team or special education case manager at your school. *
Required
Your Name *
Your answer
Your email address *
Your answer
District *
School *
Position/Title *
Your answer
Student's Name *
Your answer
Student's Grade/Age *
Your answer
Student's Gender *
Primary Language *
Your answer
Please select the current services this student is receiving: *
Required
Provide a brief explanation of how this student's social interactions, communication, and/or behavior adversely affect his/her performance in the academic setting: *
Your answer
Please select the child's social interaction characteristics that impact his/her performance in the academic setting: *
Required
Please select the child's communication characteristics that impact his/her performance in the academic setting: *
Required
Please select the child's behaviors and characteristics that impact his/her performance within the academic setting: *
Required
Please select the most significant behavior/characteristic from the above checklist and provide an example of this student exhibiting this behavior within the academic setting: (example: "When we have group time on the carpet in the morning, student must read the entire alphabet off the rug before being seated, keeping the class from starting our daily activities.")
Your answer
When is the best time/day to visit for an observation of this student? (Please be specific, i.e. during math centers from 11:20-11:45am MWF)
Your answer
Please provide us with any other information pertinent to this referral process:
Your answer
Please confirm that you have consulted with your building-based School Psychologist and he/she has completed an informal observation on this student. *
Required
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