ADOS Assessment/Form | One of the Kids

ADOS ASSESSMENT INTAKE INFORMATION

Please complete and return to OOTKS prior to your scheduled ADOS assessment. If Intake information is not received within 24 hours of your scheduled assessment, our office may contact

you to re-schedule.

Parent Name

Phone

Child Name

Referring Physician

Date of Birth

Primary Pediatrician

Date of follow up appointment with referring Physician?

Type of Referring Physician

Pediatrician

Neurologist

Other Specialist

Primary Language spoken in the home

Is child able to walk independently? Yes or No

Any other languages spoken in home? Yes or No

Any other Diagnoses? Yes or No

Any current medications? Yes or No

This should be the level of functional language that your child uses INDEPENDENTLY, not prompted language or repeating things that other say. Please select from one of the below options.

CAREGIVERS MAIN CONCERNS: Please describe your main concerns regarding your child’s development.

CHALLENGING BEHAVIORS: Please provide any information regarding behaviors that your child engages in, including, but not limited to: tantrums, aggression, self-injurious behavior and/or repetitive behaviors

Anything else you would like us to know about your child?