Harmony Autism Therapy- Milestone 2: Patient Profile

Welcome to Harmony Autism Therapy's

MILESTONE 2 out of 4

Patient Profile

________________________

This form should take about 15 minutes to complete. You will be asked about your child's strenghts and areas of need in speech and language, social and behavior.

It is important that you answer these questions with two factors in mind:

1) Does your child demonstrate the skill consistently (on a daily basis/at least 90% of the time)?

2) Does you child demonstrate the skill independently (without any prompts)?

Please take the time to share as much detail as you wish. The more information we are given, the less time we will need to take getting the information later.

Thank you for choosing Harmony Autism Therapy for your child’s ABA therapy needs!

We look forward to helping your child achieve a life with full potential!
Patient Information
Patient's Full Name *

First Name Last Name
Patient's Date of Birth *

Month Day Year
Date

Speech & Language Skills
Speech & Language STRENGTHS *

Speech & Language Problems *

Problem

Not a problem

1. Doesn't babble

2. Doesn't have 1-2 words

3. Doesn't talk like same age peers

4. Had speech, but no longer speaks

5. Mostly just repeats what he/she hears

6. Abnormal use of pitch, intonation, rhythm or stress

7. Speech is abnormally loud or quiet

8. Difficulty whispering

9. Repeats last words or phrases previously heard

10. Makes vocal sounds but not understandable

11. Often uses short, incomplete sentences

12. Pronouns are often inappropriately used

13. Has a very high vocabulary for age (mostly nouns, letters, #s)

14. Difficulty understanding directional terms (front, back, before, after)

15. Describes items (child says, "big," "round," or "bounce" when shown a ball)

16. Identifies items by categories (points to a cow when asked, "show me the animal" in a book)

17. Answers WH-questions (who, where, when)

18. Asks WH-questions (where? who? where?)

Explain Speech & Language Problems *

Social Skills
Social Skill STRENGTHS *

Problems with Social Skills *

Problem

Not a problem

1. Very little or no eye contact

2. Resistance to being held or touched

3. Tends to get too close when speaking to someone (lack of personal space)

4. Responds to social interactions, but does not initiate them

5. Does not generally share observations or experiences with others

6. Difficulty understanding jokes, figures of speech or sarcasm

7. Difficulty reading facial expressions and body language

8. Difficulty understanding the rules of conversation

9. Difficulty understanding group interactions

10. Aversion to answering questions about themselves

11. Gives spontaneous comments that seem to have no connection to the current conversation

12. Makes honest, but inappropriate observations

13. Seems unable to understand another’s feelings

14. Prefers to be alone, aloof or overly-friendly

15. Difficulty maintaining friendships

16. Finds it easier to socialize with people that are older or younger, rather than peers of their own age

17. Unaware of/disinterested in what is going on around them

18. Talks excessively about one or two topics (dinosaurs, movies, etc.)

19. Overly trusting or unable to read the motives behinds peoples’ actions

20. Minimal acknowledgement of others

Explain SOCIAL Problems *

Behavior
Behavior STRENGTHS *

Problems with BEHAVIOR *

Problem

Not a problem

1. Verbal outbursts.

2. Displays unusual movements

3. Under sensitive/stimulated

4. Overly sensitive/stimulated (doesn’t like tags on clothes, doesn’t like the sound of some toys)

5. Obsession with objects, ideas or desires

6. Ritualistic or compulsive behavior patterns (sniffing, licking, watching objects fall, flapping arms, spinning, rocking, humming, tapping, rubbing clothes)

7. Fascination with rotation

8. Play is often repetitive (lining up objects or repeating same movements with objects/toys)

9. Many and/or varied collections

10. Unusual attachment to objects

11. Quotes movies , tablets, and/or video games

12. Difficulty transferring skills from one area to another

13. Perfectionism in certain areas

14. Frustration is expressed in unusual ways (spins or rolls on ground, etc)

15. Feels the need to fix or rearrange things

16. Transitioning from one activity to another is difficult

17. Difficulty attending to some tasks

18. Gross motor skills are developmentally behind peers (riding a bike, skating, running)

19. Fine motor skills are developmentally behind peers (hand writing, tying shoes, scissors)

20. Inability to perceive potentially dangerous situations

21. Extreme fear (phobia) for no apparent reason

22. Unexpected movements (running out into the street)

23. Difficulty sensing time (knowing "tomorrow" or "later" or "2 more days")

24. Difficulty waiting for their turn (such as in a line)

25. Causes injury to self (biting, banging head)

26. Sensitivity or lack of sensitivity to sounds, textures (touch), tastes, smells or light

27. Difficulty with loud or sudden sounds

28. Unusually high or low pain tolerance

29. Intolerance to certain food textures, colors or the way they are presented on the plate (food can’t touch)

30. Inappropriate touching of self in public situations

31. Desires comfort items (blankets, teddy, rock, string)

32. Laughs, cries or throws a tantrum for no apparent reason

33. Resists change in the environment (people, places, objects)

34. An emotional incident can determine the mood for the day - emotions can pass very suddenly or are drawn out for a long period of time

35. Becomes overwhelmed with too much verbal direction

36. Tends to either tune out or break down when being reprimanded

37. Calmed by external stimulation - soothing sound, brushing, rotating object, constant pressure (hammock, rolled in a blanket)

38. May need to be left alone to release tension and frustration

Explain BEHAVIOR Problems *
Write the # and explain how it relates to your child’s PROBLEM BEHAVIOR. For example: "#20. Doesn't understand danger. He will wander off without making sure I'm nearby." "#32. He tantrums (crying, falling to floor, stomps feet) at least 3 times a week when he doesn't get his way”

Reinforcers
In order to begin teaching your child, we need to identify HIGHLY PREFFERED items/food/activites in order to maintain your child's motivation.
Foods/Drinks *
(i.e., gummy bears, cheese, popcorn, pudding)
Indoor activities *
(i.e., Playdoh, legos, slinky, slime)
Outdoor activities *
(i.e., swing, wagon ride, swimming)
Physical/Social *
(i.e., tickles, hugs, chase)
If left alone, how would your child spend his/her time? *
(i.e., walk around or sit and stare at spinning wheels)

Additional Information
Any other skills that are deficits or behaviors that you want addressed?
Any addition information you would like us to know?

Signature
Person Completing This Form *

First Name Last Name
Email *
example@example.com
By signing I am confirming that the information provided in this form is accurate, to the best of my knowledge. *
Date *

Month Day Year
Date
Should be Empty:

Welcome to Harmony Autism Therapy's

Patient Information