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ASD Questionaire
Complex Care Counselling
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ASD Questionaire
Autism Client Questionnaire
You are?
First Name?
*
Surname Name ?
*
GP Practice?
*
GP Practice Name
Date of birth
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Your Autism
Have you been diagnosed?
No
Aspergers
Autistic disorder
RET
Kanner's
pervasive disorder
If yes, with which?
Diagnosed by who?
GP
Neurologist
Other
Diagnosed by who?
What year were you diagnosed?
If don’t know the exact year, approx is suitable
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Have you got a history of a neuro-developmental conditions
History – Multi-Select
No
Learning disabilities
Attention deficit hyperactivity disorder
Psychiatric difficulties
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Your Autistic Traits
Communication – Multi-Select
Find joining in conversation difficult
Speak in a flat, monotone voice, or not speak
Have trouble relating to other people’s thoughts or emotions
Use repetitive language
Find it hard to read someone’s body language and emotions.
Find that others don’t understand how you are feeling
Dominate conversations
Find it easier to talk ‘at’ people, rather than engaging in a two-way conversation
Have trouble reading social cues
Find ‘small talk’ difficult
Take things literally
Be blunt in your assessment of people and things
Find it difficult to maintain eye contact when you are talking to someone
Have your own unique phrases and descriptive words.
Find building and maintaining close friendships and relationships difficult
You may make faces that others find unusual
You may make gestures when speaking with people
New Option
Provide excessive information on the specific topics
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How, Does Autism Effect You?
Behaviours- Multi-Select
Prefer consistent routine and schedules
Upset when something happens that you did not expect to happen
Have trouble regulating your emotional responses.
Are bothered if your things are moved or rearranged by someone
Get upset or anxious should that routine or schedule be changed.
Have a series of repetitive rituals or behaviours
You make noises in places where you are expected to be quiet
Preference for highly specific interests or hobbies
Have difficulty multi-tasking
Have a very strong reaction or no reaction to smell
Like operating solo – both at work and play.
Have a very strong reaction or no reaction to noise
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How Does Autism Impact You?
Impact – Multi-Select
Problems in obtaining, regularly attending or sustaining employment or education.
Difficulties in initiating or sustaining social relationships.
Previous or current contact with mental health or learning disability services.
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Any, Diagnosed Conditions
Co-existing Disorders?
None
Attention deficit hyperactivity disorder
BPD
Bi-poler
Fragile X syndrome
Gastrointestinal or digestion problems
Insomnia
Intellectual disability
Sensory processing disorder
Selective Mutism
Seizures
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Have You Got Any Learning Difficulties
Learning Difficulties – Multi-Select
None
Dyslexia
ADHD
Dyscalculia
Dysgraphia
Dyspraxia
Other
Learning Difficulties – Multi-Select
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Family
Relationship
Single
Divorced
Live-in-Partner
Married
Other
Relationship
Children under 18?
Yes
No
Other
Children under 18?
How many children?
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Employment
Employed?
Yes
No
Other
Employed?
Vocation?
Unemployed
Medically Unable to Work
ASD Limits My Work Opportunities
Carer
University
Retired
Other
Other
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Your Counselling History
Have you had counselling before?
No
Yes
Other
Other
Who paid?
NHS
Employer
Myself
Other
Who paid?
What year? (approx)
Approx how many sessions?
Any other counselling?
No
Yes
Other
Other
Can you write who paid, when & how many sessions please?
Approximately
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Do you want to add anything?
If you are human, leave this field blank.
Submit