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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 (
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.
Your email address
Henry-Stark Special Education
Annawan Grade School
Annawan High School
Bradford Grade School
Bradford Jr. High School
Cambridge Grade School
Cambridge Jr./Sr. High School
Galva Elementary School
Galva Jr./Sr. High School
Geneseo High School
Geneseo Middle School
Millikin Elementary School
Northside Elementary School
Southwest Elementary School
Kewanee High School
Stark County Elementary
Stark County Jr./Sr. High School
Wethersfield Elementary School
Wethersfield Jr./Sr. High School
Prefer not to say
Please select the current services this student is receiving:
Special Education Services (IEP)
Speech and Language Therapy
Tiered Intervention services (RtI)
Provide a brief explanation of how this student's social interactions, communication, and/or behavior adversely affect his/her performance in the academic setting:
Please select the child's social interaction characteristics that impact his/her performance in the academic setting:
Lack of social reciprocity (i.e. difficulty with back-and-forth conversation; not able to share interests, emotions, or flat affect; no initiation or response to social interactions)
Delays in nonverbal communicative behaviors (i.e. awkward nonverbal communication; abnormal eye contact and/or body language; difficulty with understanding and/or using gestures; lack of facial expressions)
Difficulty developing, maintaining, and understanding relationships (i.e. difficulties adjusting behavior to suit various social contexts; lack of imaginative play; lack of interest to make friends)
Please select the child's communication characteristics that impact his/her performance in the academic setting:
Delayed in or lack of spoken language
Unable to use communication effectively for social purposes (i.e. lack of using greetings or sharing information at inappropriate times)
Unable to change communication to match context or the needs of the listener, such as speaking differently in a classroom than on the playground, talking differently to a child than to an adult, and avoiding use of overly formal language.
Difficulties following rules for conversation and storytelling (i.e. unable to take turns in conversation or rephrasing when misunderstood)
Difficulties understanding what is not explicitly stated (i.e., making inferences) and nonliteral meanings of language (e.g., idioms, humor, metaphors, multiple meanings that depend on the context for interpretation).
Please select the child's behaviors and characteristics that impact his/her performance within the academic setting:
Stereotyped or repetitive motor movements, use of objects, or speech (i.e., stereotyped behaviors, lining up toys or flipping objects, echolalia-repeating, idiosyncratic phrases).
Routine-based personality and/or behaviors (i.e. difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day).
Abnormal, highly restricted, fixated interests (i.e., strong attachment to or preoccupation with unusual objects, such as fans).
Abnormal responses to sensory input and/or aspects of the environment (i.e., indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement)
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.")
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)
Please provide us with any other information pertinent to this referral process:
Please confirm that you have consulted with your building-based School Psychologist and he/she has completed an informal observation on this student.
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