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AAA Autism Info (2021-2023)
Survey about Children with Autism in Lebanon
* Indicates required question
Parent's Name or Phone Nbr
*
Your answer
Mother/Father (Filling this Form)
*
Mother
Father
Parent's Job (Mother/Father Filling this Form)
*
Your answer
Parent's Education (Mother/Father Filling this Form)
*
Middle School
High School
Technical School
University
PhD
Other:
Required
Email
*
Your answer
Parents' Address
*
Beirut
Mount-Lebanon
North-Lebanon
South-Lebanon
Bekaa
Parents' Marital Status
Married
Separated/Divorced
Other:
Clear selection
Child Living with Parents
Yes
No
Other:
Clear selection
Name of the Child (or Abbreviation)
Your answer
Child's Gender
*
Boy
Girl
Did your child attend an inclusive school previously
*
Yes (Before the age of 6)
Yes (Until Now)
No
Other:
Child' school
*
Mainstream without Shadow Teacher
Mainstream with Shadow Teacher
Institution with Ministry of Social Affairs
Specialized School
Home Schooling
Other:
Child' class (if Child attends a mainstream school)
*
Your answer
Name of the school/institution
Your answer
Can your child read & write
*
Yes (Read & Write)
Yes (Very Little)
Read Only
Write Only
No
Other:
Child's Date of Birth (Month, Day, Year)
*
MM
/
DD
/
YYYY
Age of the Child When you suspected Autism
*
Your answer
First Sign Why you suspected Autism
*
Lack of Speech
No Eye-Contact
No Response to his own name
No Pointing at Objects
No playing with Peers
Lack of Sleep
Toe-Walking
Stereotypical behavior
All of the Above
Other:
Required
Child's age when you got an official Diagnosis (in months)
Your answer
What level of your child's autism (Level 1 is mildest autism, Level 10 is very severe autism)
*
Mild Autism
1
2
3
4
5
6
7
8
9
10
Severe Autism
Child's Hobbies
*
Swimming
Biking
Running
Drawing
Eating
Playing Music
Watching TV
Listening to Music
Horse riding
Walking/Hiking
Cooking
Other:
Required
Is your Child Autonomous
Yes
No
Needs help
Other:
Clear selection
Is your child Verbal
*
Yes (fluent)
No
Child can say a few words
Child can say a few sentences
Does the child with autism have siblings
*
Yes
No
1
2
3
A sibling with disability
Other:
Required
Who was the first to notice your child is different
*
Family
Pediatrician
Caregiver
Kindergarten
Neurologist
Psychologist
Other:
Required
Any Special Diet is your child following
*
Child is a picky eater
GF (Gluten Free)
CF (Casein Free)
GFCF (Gluten Free - Casein Free)
Vegan (avoids animal flesh and eggs, but do consume dairy products)
Vegetarian (avoids all animal and animal-derived products)
Another Food Intolerance
None
Other:
Required
Who gave you the official diagnosis
*
Pediatrician
Neurologist
Psychologist
Psychiatrist
Pediatric Psychiatrist
Pediatric Neurologist
Other:
Required
Does your child go to Specialists
*
Pediatrician
Neurologist
Psychologist
Psychiatrist
Pediatric Psychiatrist
Pediatric Neurologist
ABA Therapist
Speech Therapist
Psycho-Motor Therapist
Occupational Therapist (OT)
Yoga
Other:
Required
Any other Medical Condition
*
None
ADHD
Epilepsy
Gastro
Allergy
Hearing
Myopia
Food Intolerance
Sensitivity
Anxiety
Attention Deficit
Other:
Required
Any Medication
*
No
Allergy
ADHD
Epilepsy
Gastro
Other:
Required
What Tests/Exams have you done
*
Hearing Test
MRI
EEG
Psychological Assessment
Psychomotor Assessment
Genetic Testing
Behavioral Screening
Developmental Screening
Speech & Pathology
VB mapping
Other:
Required
What is the most challenging behavior of the Child
*
Sleep
Lack of Communication
Anxiety
Eating
Aggressiveness
Outings
Tantrums
Attention Deficit
OCD
Sensitivity
Hyperactivity
Other:
Required
Have you ever attended a parent support group
*
Yes
No
Other:
Have you ever attended trainings for parents of children with autism
*
Yes
No
Other:
What kind of training you would like to attend
*
Your answer
Are you a member of AAA
*
Yes
No
I want to join
Other:
Would you like to be an active member in Autism Advocacy
*
Yes
No
Maybe later
Other:
What are your main fears for the future
*
Your answer
Preferred Language
Arabic
English
French
Other:
Clear selection
Suggestions
Your answer
PLEASE FOLLOW AAA SOCIAL MEDIA PAGES !
https://www.facebook.com/AAA.AutismAwarenessAssociation
https://www.instagram.com/AAA_Autism_Awareness
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