Questionairre for Autism Study

Name

Email Address

Child's First Name

Child's Birth Date, Time, and City

Parent #1 Birth Date, Time, and City

Parent #2 Birth Date, Time, and City

Is Parent #1 Mom or Dad? Is Parent #1 Mom or Dad? Mom Dad

Is Parent #1 the Biological Parent? Is Parent #1 the Biological Parent? Yes No

Child's Gender

Is Parent #2 the Biological Parent? Is Parent #2 the Biological Parent? Yes No

At what age was your child diagnosed with autism?

Will you describe in the best way you can the level of functionality of your child at home and out in the world based on your own perception? Please include whether or not they attend school outside the home.

What are your child's biggest challenges in life? Please describe in detail.

What are your child's biggest strengths and talents?

What are your child's interests? Does he/she apply their strengths and talents to these interests?

How does your child handle being autistic in what is considered a neurotypical world? Are they sensitive to the opinions of others? Do they fit in at school? Do they embrace their uniqueness?

Has your child experienced any trauma in their life? This would be anything that caused severe emotional distress such as a move, divorce, death of a loved one, bullying, changing schools, an incident with a friend, etc. Please state their age and date when it happened if possible.

Please describe life challenges for Parent #1.

Please describe Parent #1's strengths and talents.

Please describe how your child has helped you grow, Parent #1.

Please describe life challenges for Parent #2.

Please describe Parent #2's strengths and talents.

Please describe how your child has helped you grow, Parent #2.

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