Department for Education, Children and Young People
 Tasmanian Autism Diagnostic Service (TADS)		

 Tasmanian Autism Diagnostic Service (TADS)
Electronic Service Provider Questionnaire (4 pages)
Use mouse or tab to enter grey areas to complete required information. The document must be saved or attached
 to an email. Please send saved document to autismassessment@decyp.tas.gov.au or print and post to GPO Box 169, HOBART 7001.
Please complete ALL details in table below
Child/Young Person's Name:   <PtFullName>	Age: <PtAge>     Grade: <Child's grade in school>	
Name of person completeing questionnaire:  <UsrName>	Date completed:   <TodaysDate>	
Position: <Type of clinician>	 How long have you known the child/young person:  <How long have you known the child>  	
Contact Details: - Phone:  <UsrPhone>	Email: <PracEmail>	
 Name of Service/School:  <LocationName>	Name of School Psychologist:  <Name of School Psychologist if appropriate>	

Please provide detailed information of your observations of the child, considering how they interact with you and their peers (if applicable). Your observations and comments are a critical component of the assessment process.

Social Communication
1. Which of the following best describes this child’s or young person’s current speech/language abilities: 
	 Non-verbal	
		
	 Uses single words only	
		
	 Uses short phrases, eg “I want drink”, “Daddy go car” and “Mummy come here”. 	
		
	  Uses fluent speech and is able to talk about events that happened in the past or future eg “I went to the shop and bought 	
		
	  a lolly” and “Last week I got an award for spelling”	

2. Can this child or young person have a back and forth conversation with adults and their peers? For example, can they              engage in turn taking during a conversation with others? Do they engage in social chit-chat? Can they talk about different         topics?

	 YES	
		
	 NO - please provide details	

3. Does this child or young person regularly show and share their interests and achievements with others?

	 YES - if yes, do they monitor the other person's reaction		 YES		 NO	
						
	 NO 					

4. Does this child or young person spontaneously offer comfort to others if they are hurt, ill or distressed? 

	 NO	
		
	 YES - if yes, how does the child offer comfort? Please provide details:	

5. Does this child or young person appropriately respond to the social approaches of their peers and adults? For example, if a      peer approaches to share their interest or initiate a conversation or play, do they engage?  

	 YES - if yes, does the child or young person try to maintain the interaction?		 YES		 NO	
						
	 NO 					

Tasmanian Autism Diagnostic Service – 2020
Mail: GPO Box 169 HOBART TAS 7001      Phone: 03) 6166 1100 
autismassessment@decyp.tas.gov.au
6. Does this child or young person make appropriate eye contact? For example, do they look at you while talking and listening?

	 YES	
		
	 NO	

7. Does the child or young person use a range of gestures spontaneously, without being prompted? For example, pointing,           beckoning someone to come and using their hands to indicate size or direction? 

	 YES	
		
	 NO - please provide details	

8. If the child or young person does use a range of gestures as described above, do they combine their gestures with other           types of non-verbal behaviour? For example: gesturing to indicate the presence of a preferred person with an excited facial      expression.  

	 YES	
		
	 NO	

9. Does this child or young person show a range of subtle facial expressions? For example: surprise, amusement and                  embarrassment.  

	 YES - do they direct their facial expressions to others to communicate their feelings?		 YES		 NO	
						
	 NO 					

10. Can this child or young person read other people’s body language? For example, if a person points in a certain direction           can they follow their point? Can they tell others may be bored or annoyed? Do they understand when someone gives them       a stern look?

	 YES	
		
	 NO	

11. Does this child or young person have any particular friends or a best friend? 

	 YES - if yes, is the friendship mutual and reciprocal?		 YES		 NO	
						
	 NO 					

12. Does this child or young person have any difficulties with group work and/or cooperative play?

	 NO	
		
	 YES - please provide details:	

13. Does this child or young person prefer to play with others of a different age? 

	 NO	
		
	 YES - please provide details:	

Tasmanian Autism Diagnostic Service – 2020
Mail: GPO Box 169 HOBART TAS 7001      Phone: 03) 6166 1100 
autismassessment@decyp.tas.gov.au

Interests, Behaviour and Skills

1. Does this child or young person regularly display any unusual physical mannerisms or repetitive body movements, eg hand      flapping, finger flicking and spinning?

	 NO	
		
	 YES - please provide details:	

2. Does the child or young person focus on particular parts of objects? For example, spinning wheels or lining up items or             organising items according to size, colour, type or date.

	 NO	
		
	 YES - please provide details:	

3. Does this child or young person regularly repeat words, phrases or sentences exactly as they have heard in the past? For         example, from other people or from the television. 

	 NO	
		
	 YES - please provide details:	

4. Does this child or young person cope if their activities or routines are interrupted?

	 YES	
		
	 NO - please provide details:	

5. Is the child or young person concrete or literal in the way they think and/or do they ask repetitive questions despite already        knowing the answer?

	 NO	
		
	 YES - please provide details:	

6. Does this child or young person have any special routines or things that they like to do in a particular way or order? For             example, pacing, a greeting ritual, an insistence on organizing items on their desk in a certain way, or needing to be first in       line all the time?
 
	 NO	
		
	 YES - please provide details of the routine and how the child reacts when they cannot complete the routine:	

7. Does this child or young person display any strong or unusual interests? For example, is there anything they like to spend a      lot of their time doing or talking about?

	 NO	
		
	 YES - please provide details:	

8. Does this child or young person have any unusual sensory interests or reactions, eg sniffing objects, mouthing non-food           items, over-sensitivity to noise, tags and seams? Does the child or young person not react to differences in temperature           (cold and heat) or to pain?

	 NO	
		
	 YES - please provide details:	

Tasmanian Autism Diagnostic Service – 2020
Mail: GPO Box 169 HOBART TAS 7001      Phone: 03) 6166 1100 
autismassessment@decyp.tas.gov.au
Academics

1. How is the child or young person doing academically in comparison to their peers (eg previous numeracy/literacy results)?

requires significant curriculum adaptation		

below average		                 Average 		    above average		

2. Does the child have a Learning Plan?
		
   YES		                       NO 		

3. Does the child or young person require educational adjustments and additional support to access the curriculum and/or to        engage with others in the classroom or playground?

	 NO	
		
	 YES - please provide details:	

4. What are your two main concerns regarding this child or young person?

[a]	 	
		
[b]	 	

What are the child’s or young person’s strengths? Consider how the child or young person contributes to the childcare/classroom setting, what they do well, whether they volunteer to help others, and if they are considerate of others. What are their relative academic strengths? 

	

Please provide any additional concerns or comments you may have below. You may like to consider whether the child has any ‘quirky’ behaviours not mentioned in the questionnaire or what causes them the most upset and how often this is a problem:

	

Please note information provided on this form 
may be used within the diagnostic report

Please return the completed questionnaire to the child’s parents, or to: 

Tasmanian Autism Diagnostic Service – 2020
Mail: GPO Box 169 HOBART TAS 7001      Phone: 03) 6166 1100 
autismassessment@decyp.tas.gov.au