BIG KID ACADEMY
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.
Date of Birth
Date of follow up appointment with referring Physician?
Type of Referring Physician
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?