1. What age is your child?
2. What is their sex? Male Female
3. Does he/she have siblings with special needs? Yes No
4. What diagnosis has he/she been given or do you suspect is most likely? Autism
ADD / ADHD
Asperger Syndrome
Down Syndrome
Cerebral Palsy (Include age of onset)
Language disorder
Other
5. Does he/she have physical disabilities? Yes No Please Explain:
6. What is his/her reading ability? None Minimal Fair but without comprehension Good with some comprehension Very good with comprehension
7 Does he/she share in two-way dialog? Yes No
8 Does he/she answer direct questions? Yes No
9 Can he/she count? Yes No
10 Can he/she match colours? Yes No
11 If he/she has favourite colours, please list them?
12 If he she has aversion to certain colours, please list them.
13 Can he/she match shapes? Yes No
14 Does he/she recognize big/small, long/short, fat/thin? Yes No
15 Does he/she understand his/her position such as ‘above, below, next to, beside’? Yes No
16 If he/she has favourite art or craft hobbies, please circle. Colouring Painting Drawing Other
17 If he/she enjoys pictures, what kind? Cartoons Photos Abstract Computer Generated Other
18 If he/she has favourite television show(s), video(s) or movie(s), please list.
19 If he/she enjoys music, please list.
20 If your child is interested in interacting with others, what is his/her ‘age’ when it comes to socializing in comparison with their actual age? Actual age Socializing age Prefers not to interact with others
21 Does your child seek physical contact with you or others? Yes No
22 Does your child engage in twiddling, flapping or spinning? Yes No Sometimes
23 What types of therapy have you found helpful? Examples:
Music, Sensory, Speech,
Parental support group,
Conditioning, Counselling,
Medication, Holding,
24 If your child attends school, what kind? Examples:
Special needs school,
Mainstream,
Mainstream with a special needs assistant,
Autism specific or ABA school.
25 If you or any of your child’s carers ever used reward charts with your child,
What did they use them for?
 Examples:
Potty training, Eating issues, Bedtime issues,
Bath time issues, Getting Ready, Sharing
Chores, Reading / Writing,
Patience / Waiting,
26 If a reward chart was used was it successful?
 Yes No Somewhat
27 Does your child understand time (minutes, hours, days, weeks)?
 Yes No Somewhat
28 Tick whichever applies to your child.
1. Understands earning a reward, but needs immediate reward/gratification.
2. Understands earning a reward, and enjoys anticipation.
3. Special needs makes understanding rewards too difficult.
4. Does not understand rewards or trade offs.
5. Not sure.
29 Please circle all issues your child has that you feel are especially difficult due to their special needs in column 1. In column 2 circle which issues you would most like to work on to improve with your child.
 Examples:
Click here for a detailed list of examples
30 Is your child aware of its own special needs? Yes No Not Sure
31 Does your chi ld seem to think they are different? Yes No Not Sure
32 Does your child recognize other special needs children as being different? Yes No Not Sure
33 Do you think artwork showing a mixture of children, some with an obvious
different look (like down syndrome or Cerebral Palsy) would be appropriate in a special needs book?
Yes No Not Sure
34 Do you think artwork depicting children that show subtle special needs would
be appropriate in a special needs book?
 Yes No Not Sure
35 Do you think artwork depicting physically disabled children would be appropriate in a special needs book? Yes No Not Sure
36 What is your most effective way of negotiating with your child?
 1. Trade-offs / Rewards
2. Loosing privileges
3. Gaining privileges
4. Nothing has worked .
37 List all hobbies your child enjoys. Examples:
Puzzles, Games, Blocks, Lining up toys,
TV / movies / videos, Radio / DVD’s,
Dancing, Playing an instrument(Name Instrument), Bathing / Swimming, Swinging,
Rough play, Gymnastics, Camping / canoeing, Climbing, Horse riding, Caring for animals, Other
38 Which does your child seem to prefer? 1. Simple pictures
2. Very detailed pictures
3. Neither
4. Not sure
39 Is there something you have found is very effective at motivating your child? Please List.
40 Do you find the following cartoon inappropriate or offensive? (Click here for cartoon).
41 If every day skills are a goal for your child at this time, which ones? Examples:
Dressing, Bathing, Toilet training,
Basic housework, Cooking,
Shopping, Using the Bus / train,
Understanding money,
Understanding danger (traffic / strangers)
42 Please list any books you have found helpful
   
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Thank you for taking the time to share you and your child’s experiences.


Lisa O Duinn
Author