Client name: IAPTus no:

Name of assessor: Date:

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Prior to starting the interview: Best telephone contact no:

NOTES FOR ASSESSOR: Please be aware that it is not expected that this assessment take
longer than 50 minutes. This form contains ideas about things you may want to enquire
about to support you to make a referral to the ASD service; however it is not expected that
you are able to answer all of the questions presented here. The ASD service is looking for a
rationale for an ASD assessment only.

Introduction
Explain the purpose of the assessment, how long it will take (up to 1 hr), what it will cover, and
what will happen following the assessment. Explain confidentiality.

Presenting problem(s):
(1) Why have they asked for a screening of ASD? Why do they think they have ASD?

Additional information:
Ask about current and past employment, significant relationships, family status (married, children
etc), and current medication (incl. dose).

Risk & risk management

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Autism screening

Your assessment should assess for evidence of long-standing impairments in imagination, social
relationships and social communication:

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 AAA Assessment

The patient should have been asked to complete these in advance of their
appointment. This is comprised of three questionnaires:

 AQ (Autism Spectrum Quotient) (self-report)

 EQ (Empathy Quotient) (self-report)
 RQ (Relatives Questionnaire) (to be completed by a caregiver who has known
client since infancy)

If the patient has not completed these, do not worry as they will be asked to complete
these when they are invited to attend their ASD assessment with the ASD service.

If you do have completed questionnaires available, you can then use the AAA Excel
score sheet to calculate the scores and use these as supporting evidence for your
referral. Please ensure you save the spreadsheet as new before entering and calculating
your client’s data.

Scores:

AQ: _________ (scored out of 50, 80% of individuals with ASD score 32 or more)

EQ:__________ (scored out of 80, 80% of individuals with ASD score 30 or less)

RQ:__________ (scored out of 31, 87.5% of children with AS score 15 or more)

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Developmental History
If possible, a developmental history should be gathered from a caregiver who has known client
well since infancy, in addition to the client. Clients should be asked to bring someone who can
provide this information to your appointment, but do not worry if they attend alone.

This assessment form separates the questions for carer and client, but in practice you might ask
both the same questions and record their responses separately. It is not xpected that you conduct
two separate interviews for client and caregiver.

Name of caregiver interviewed (if present) and relationship to the client:

……………………………………

Caregiver interview
This can be guided by the information you have already gleaned from the RQ, but may include
some or all of the following questions:

1) Were there any developmental delays evident by the age of 3 years? (e.g. delays in
speech and language, development of social attachments, reciprocal social
interaction or symbolic play?)

2) Did the client show interest in peers growing up? Did the join in with play, watch
enthusiastically, understand turn-taking?

3) Was interaction with age peers appropriate, i.e. friendly and reciprocal?

4) Did they show sympathy and affection to peers?

5) What was the quality of their peer friendships?

6) Did they have pretend or imaginative play?

7) Did they show curiosity about themselves/ others/ the world?

8) Did they cling to or collect or have a fascination with specific objects?

9) Did they have any unusual food fads?

10) Did they ask repetitive questions or talk about repetitive themes?

11) Did they amass facts on certain subjects?

12) Did they have a marked fascination with particular TV programmes?

13) Did they have an intense interest in any particular person?

14) Did they have any repetitive routines?

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 15) How did they respond to changes in routines?

16) Are there any other reasons why the client or relative thinks that their difficulties
may fit with a diagnosis of ASD?

These questions re designed to support you to gain information to support your referral to the
ASD service. It is not expected that you are able to answer all of these questions. It is helpful if
you can include in your referral information about possible problems in the following areas:

-social and communication difficulties (e.g. difficulties with eye contact, stereotyped speech,
feeling misconceived, taking things literally, inadvertently offending others), sensory sensitivity,
ritualistic behaviours not obviously part of an OCD process, narrow interests.

Notes:

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Client interview
This should be guided by the information you have already gleaned from the AQ and EQ (by
asking clients to elaborate on their answers), but may also include some or all of the following
questions:

1) Why have you requested a diagnostic assessment for ASD?

.
2) What has led you to believe that you may have a diagnosis of ASD?

3) Please describe the difficulties that you have that you believe may be due to an
ASD..

4) Were these difficulties present in childhood? Please give examples.

5) How do these difficulties impact on your life now? Please give examples.

6) Have you had any assessments for ASD in the past? What were the outcomes of
these.

7) How easy do you find it to read other people’s emotions and facial expressions?

8) How easy do you find it to “read between the lines

9) Have you ever had difficulties making friends or maintain relationships?

10) How did you find maintaining peer relationships when you were at school?

11) How do you respond to unexpected changes to your routine?

12) When you read a book, do you find it easy to create a picture of the story in your
mind?

13) Do you experience any sensory sensitivity, e.g. to noise, light, particular articles
of clothing?

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Notes: