Autism Treatment Evaluation Checklist (English)

1. Information

Name of Child (Last, First)

Sidhaan singh

Sex

Male

Age

Date of Birth (format: MM/DD/YYYY, Example: 09/25/1998)

07/01/2016

Diagnosis:
Autism

Form completed by and relationship

Mother

ATEC User

Mother/Father

Other (please explain):

Your email address [used to email results to you and include you on ARI's email notification list]. Note:
it may take up to 60 minutes for the email to arrive. You may also want to check your spam inbox. In
addition, please make sure that your email account accepts emails from ATEC@autism.com in order to
receive the PDF attachment. If not, you can copy and paste the results from the final page or your
scores will be lost.

simrat.anand@gmail.com
2. I. Speech/Language/Communication
 Please indicate how true each phrase is:
I. Speech/Language/Communication: Not true; Somewhat true; Very True

Not true Somewhat true Very true

1. Knows own name X

2. Responds to ‘No’ or ‘Stop’ X

3. Can follow some commands X

4. Can use one word at a time (No!, Eat, Water, etc.) X

5. Can use 2 words at a time (Don't want, Go home) X

6. Can use 3 words at a time (Want more milk) X

7. Knows 10 or more words X

8. Can use sentences with 4 or more words X

9. Explains what he/she wants X

10. Asks meaningful questions X

11. Speech tends to be meaningful/relevant X

12. Often uses several successive sentences X

13. Carries on fairly good conversation X

14. Has normal ability to communicate for his/her age X

3. II. Sociability
 Please indicate how true each phrase is:
II. Sociability: Not descriptive; Somewhat descriptive; Very descriptive

Not descriptive Somewhat descriptive Very descriptive

1. Seems to be in a shell – you cannot reach him/her X

2. Ignores other people X

3. Pays little or no attention when addressed X

4. Uncooperative and resistant X

5. No eye contact X

6. Prefers to be left alone X

7. Shows no affection X

8. Fails to greet parents X

9. Avoids contact with others X

10. Does not imitate X

11. Dislikes being held/cuddled X

12. Does not share or show X

13. Does not wave ‘bye bye’ X

14. Disagreeable/not compliant X

15. Temper tantrums X

16. Lacks friends/companions X

17. Rarely smiles X

18. Insensitive to other's feelings X

19. Indifferent to being liked X

20. Indifferent if parent(s) leave X

4. III. Sensory/Cognitive Awareness

 Please indicate how true each phrase is:
III. Sensory/Cognitive Awareness: Not descriptive; Somewhat descriptive; Very descriptive

Not descriptive Somewhat descriptive Very descriptive

1. Responds to own name X

2. Responds to praise X

3. Looks at people and animals X

4. Looks at pictures (and T.V.) X

5. Does drawing, coloring, art X

6. Plays with toys appropriately X

7. Appropriate facial expression X

8. Understands stories on T.V. X

9. Understands explanations X

10. Aware of environment X

11. Aware of danger X

12. Shows imagination X

13. Initiates activities X

14. Dresses self X

15. Curious, interested X

16. Venturesome - explores X

17. “Tuned in” — Not spacey X

18. Looks where others are looking X

5. IV. Health/Physical/Behavior
 Please indicate how true each phrase is:

IV. Health/Physical/Behavior: Not a Problem; Minor Problem; Moderate Problem; Serious Problem

Not a Minor Moderate Serious

problem problem problem problem

1. Bed-wetting X

2. Wets pants/diapers X

3. Soils pants/diapers X

4. Diarrhea X

5. Constipation X

6. Sleep problems X

7. Eats too much/too little X

8. Extremely limited diet X

9. Hyperactive X

10. Lethargic X

11. Hits or injures self X

12. Hits or injures others X

13. Destructive X

14. Sound-sensitive X

15. Anxious/fearful X

16. Unhappy/crying X

17. Seizures X

18. Obsessive speech X

19. Rigid routines X

20. Shouts or screams X

21. Demands sameness X

22. Often agitated X

23. Not sensitive to pain X

24. “Hooked” or fixated on certain

X
objects/topics
25. Repetitive movements (stimming, rocking,
X
etc.)

6. Subscale totals:

Subscale I - Speech/Language/Communication

20
Subscale II - Sociability

13

Subscale III - Sensory/Cognitive Awareness

23

Subscale IV - Health/Physical/Behavior

19

Subscale totals

75

Would you like these results emailed to you as a pdf file? Note: it may take up to 60 minutes for the email to
arrive. You may also want to check your spam inbox. In addition, please make sure that your email
account accepts emails from ATEC@autism.com in order to receive the PDF attachment. If not, you
can copy and paste the results from the final page or your scores will be lost.

Yes

Office use