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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
Email
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.
Pre-Verbal
Single Words
Short Phrases
Full Sentences
Conversational
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?
SUBMIT
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