My Child's Autism Report

Starting or Undergoing Autism treatment for your child?

Fill this form before starting your child’s treatment to form a baseline.

Assess your child’s outcomes by filling this form at every 4 weeks during the treatment, to know how your child is doing with the treatment.

You can also fill this form, twice a year, just to keep a check!

Autism Assessment & Treatment Evaluation
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Full Name of the child
Full Name of the child
First
Last
Child's Gender by Birth
Child's Gender Identity
Your Full Name (person filling this form)
Your Full Name (person filling this form)
First
Last
The child knows own name.
The child responds to 'No' or 'Stop'.
The child can follow some commands.
The child can use one word at a time (No, Eat, Water, etc).
The child can use two words at a time (Go home, Don't want, etc).
The child can use three words at a time (want more milk, etc).
The child knows 10 or more words.
The child can use sentences with 4 or more words.
The child explains what he or she wants.
The child asks meaningful questions.
The child's speech tends to be meaningful or relevant.
The child often uses several successive sentences.
The child carries on fairly good conversation.
The child has normal ability to communicate for his or her age.
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