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Online screening form
MUNROE-MEYER INSTITUTE
Center for Autism Spectrum Disorders
Severe Behavior and Early Intervention
Screening Form
Instructions:
The following is what we need you to send us BEFORE your child’s evaluation:
All screening forms included in this packet.
☐
Your child’s most recent education and psychological evaluations, including copies of current
educational programs (e.g., IEP).
☐
Your child’s most recent medical evaluation and medical records.
☐
All programs (previous and current) designed to treat your child’s behavior difficulties, along
with current treatment summaries (if applicable).
☐
A current videotape/DVD sample of the behaviors of concern.
You may send this information via email to [email protected] or surface mail to:
The Munroe-Meyer Institute
Severe Behavior Program
Attn: Amber Godsey
985450 Nebraska Medical Center
Omaha, NE 68198-5450
If you have any questions or need assistance please call (402)559-3563 or email to the above address.
A representative will contact you once this packet is returned to set up your child’s evaluation. Thank
you for your interest in the Severe Behavior Program and we look forward to seeing you at your child’s
evaluation.
CENTER FOR AUTISM SPECTRUM DISORDERS
Autism Diagnostic Clinic, Severe Behavior Disorders, and Early Intervention Program
Munroe-Meyer Institute
Please complete all information below:
SECTION I
NEW PATIENT INFORMATION
UNH#
Office Use only
PATIENT LABEL / PATIENT NAME
DATE OF BIRTH
PATIENT ADDRESS
CITY, STATE
MOTHER’S NAME
HOME PHONE
ADDRESS (IF DIFFERENT FROM CHILD)
ZIP
WORK PHONE
CITY, STATE
ZIP
PREFERRED EMAIL ADDRESS
FATHER’S NAME
ADDRESS (IF DIFFERENT FROM CHILD)
HOME PHONE
WORK PHONE
CITY, STATE
ZIP
PREFERRED EMAIL ADDRESS
PRIMARY CARE PHYSICIAN
ADDRESS
OFFICE PHONE
DATE OF LAST VISIT
CITY, STATE
PERSON COMPLETING FORM
PHONE
RELATIONSHIP TO CHILD
DATE FORM COMPLETED
ZIP
WHO REFERRED THIS CHILD?
ADDRESS
PLEASE DESCRIBE THE REASON FOR THIS EVALUAITON:
PLEASE DESCRIBE THE TOP 3 CONCERNS YOU HAVE FOR YOUR CHILD
1)
2)
3)
CITY, STATE
ZIP
Clinician Notes
Patient to fill out this column ONLY
SOCIAL HISTORY
PRIMARY CARETAKER:
THIS IS THE CHILD’S:
Biological Family
Adoptive Family
Foster Family
Group Home
___ Institution/out of home placement Organization Name: _______________________ (how long?
)
WHO LIVES IN CHILD’S CURRENT HOME:
Name
Age
Relationship to Child
BIOLOGICAL MOTHER:
CUSTODIAL/LEGAL GUARDIAN
AGE:
BIRTHDATE:
OCCUPATION:
HIGHEST GRADE LEVEL:
BIOLOGICAL FATHER:
CUSTODIAL/LEGAL GUARDIAN
AGE:
BIRTHDATE:
OCCUPATION:
HIGHEST GRADE LEVEL:
FOSTER/ADOPTIVE MOTHER:
CUSTODIAL/LEGAL GUARDIAN
AGE:
BIRTHDATE:
OCCUPATION:
HIGHEST GRADE LEVEL:
FOSTER/ADOPTIVE FATHER:
CUSTODIAL/LEGAL GUARDIAN
AGE:
BIRTHDATE:
OCCUPATION:
HIGHEST GRADE LEVEL:
☐Y ☐N
☐Y ☐N
☐Y ☐N
☐Y ☐N
PARENTS ARE (please check one):
Married
Divorced
Separated
Never Married
SIBLINGS/AGES:
PLEASE CHECK ANY STRESSFUL SITUATIONS YOUR CHILD HAS EXPERIENCED WITHIN THE LAST YEAR:
Death of family member
Parents’ separation
Change in parent(s) employment
Major health change in family member
Parents’ divorce
Parent’s marriage
New family member (birth, adoption, etc)
Domestic violence
Moving to a new location
PLEASE CHECK ANY OF THE FOLLOWING SITUATIONS YOUR CHILD HAS EXPERIENCED:
Physical abuse
Alcohol use
Tobacco use
CPS/Foster placement
Sexual abuse
Drug use
Legal problems/arrest
Residential placement
If yes, please provide additional detail:
SECTION II
PATIENT HISTORY QUESTIONNAIRE
Clinician Notes
Patient to fill out this column ONLY
PREGNANCY AND BIRTH HISTORY
MOTHER’S AGE AT
DELIVERY:
LENGTH OF PREGNANCY:
FATHER’S AGE AT
DELIVERY:
DELIVERY:
BIRTH WEIGHT:
WEIGHT GAIN:
Spontaneous Vaginal
Elective C-Section
BIRTH LENGTH:
Induced Vaginal
Emergency C-Section
BIRTH HEAD SIZE:
APGAR SCORE (if known)
NUMBER OF PREVIOUS PREGNANCIES: Term:
Abortions:
Premature:
Living:
PLEASE CHECK ANY PRENATAL EXPOSURES:
Alcohol
If yes, amount:
Tobacco
If yes, amount:
Prescription medications
If yes, name/reason:
Over-the-counter medications
Drugs:
If yes, name/reason:
Marijuana
Amphetamines
Cocaine
Methadone
Heroin
Other:
LSD
PCP
PLEASE CHECK ANY COMPLICATIONS DURING PREGNANCY OR LABOR:
Infections/Rash
Maternal fever
Seizures
Induced labor
Vaginal bleeding
Rh incompatibility
Gestational diabetes
Other:
Blood pressure problems
Trauma
Premature labor
WERE ANY TESTS DONE DURING PREGNANCY (Ultrasound, Amnio)?
PLEASE CHECK ANY OF THE FOLLOWING THAT WERE PRESENT AT BIRTH:
Breathing problems
Heart problems
Jaundice (yellow color)
Seizures
Oxygen therapy
Infection
Cyanosis (blue color)
Apnea
Congenital abnormalities
Needed antibiotics
Feeding problems
Other:
MEDICAL HISTORY
ARE IMMMUNIZATIONS UP TO DATE?
YES
MEDICATION/FOOD/ENVIRONMENTAL ALLERGIES:
NO
YES
NO
IF YES PLEASE EXPLAIN:
PLEASE CHECK IF YOUR CHILD HAS HAD ANY OF THE FOLLOWING MEDICAL PROBLEM
Ear Infections
Heart Problems
Kidney Problems
Muscle Disorders
Headaches
High Blood Pressure
Endocrine Disorders
Scoliosis
Vision Problems
Asthma
Diabetes
Skin Problems
Hearing Problems
Respiratory Problems
Thyroid Problems
Anemia
Meningitis
Constipation
Arthritis
Seizures
MEDICAL HISTORY
DOES YOUR CHILD CURRENTLY TAKE MEDICATIONS
YES
NO
If yes, please list medication information below. Please maintain your child’s current medication regimen at the time of
evaluation.
MEDICATION NAME:
DOSE:
REASON:
HAS YOUR CHILD TAKEN MEDICATIONS IN THE PAST
MANAGING PROVIDER:
YES
NO
If yes, please list medication information below.
MEDICATION NAME:
DOSE:
REASON:
REASON FOR DISCONTINUING:
PREVIOUS TESTING:
WHEN/WHERE:
RESULTS:
LIST PREVIOUS
HOSPITALIZATIONS:
DATE (or age):
REASON:
LIST PREVIOUS
SURGERIES:
DATE (or age):
REASON:
EEG
CT SCAN
MRI
GENETICS
Clinical Notes
Patient to fill out this column ONLY
HAS YOUR CHILD HAD A SEVERE HEAD OR BODILY INJURY?
YES
NO
IF YES, PLEASE DESCRIBE:
PLEASE DESCRIBE YOUR CHILD’S SLEEP:
PLEASE DESCRIBE YOUR CHILD’S APPETITE AND EATING HABITS:
PLEASE DESCRIBE YOUR CHILD’S TOILETING HABITS:
Pull up or Diaper
Trip Trained/Scheduled Sits
Independently Toilets
Nighttime Accidents
CURRENT/PRIOR PROFESSIONAL CONTACT
Primary Care Physician:
Yes
No
Name:
Address/Location:
Dates:
from
to
Developmental/Behavioral Pediatrician:
Yes
No
Name:
Address/Location:
Dates:
from
Psychologist / Child Psychologist:
to
Yes
No
Name:
Address/Location:
Dates:
from
to
Clinical Notes
Patient to fill out this column ONLY
CURRENT/PRIOR PROFESSIONAL CONTACT
Psychiatrist / Child Psychiatrist:
Yes
No
Name:
Address/Location:
Dates:
from
Speech Therapy:
to
Yes
No
Name:
Address/Location:
Dates:
from
to
Occupational Therapy:
Yes
No
Name:
Address/Location:
Dates:
from
Physical Therapy:
to
Yes
No
Name:
Address/Location:
Dates:
from
Other: ________________________________
to
Yes
No
Name:
Address/Location:
Dates:
from
Other: ________________________________
to
Yes
Name:
Address/Location:
Dates:
from
to
No
Clinician Notes
Patient to fill out this column ONLY
NEURODEVELOPMENTAL HISTORY
PLEASE DESCRIBE ANY DEVELOPMENTAL CONCERNS:
AT WHAT AGE DID YOUR CHILD ACCOMPLISH THE FOLLOWING SKILLS?
__________ Smile
__________ Roll
__________ Finger feeds self
__________ Babble
__________ Sit alone
__________ Spoon feeds self
__________ Say first word
__________ Crawl
__________ Drink from open cup
__________ Put 2 words together __________ Walk
__________ Undress completely
__________ Know first name
________ _ Kick a ball
__________ Shoes on correct feet
__________ Print name
___________ Pedal Tricycle
___________ Ties shoes with bow
PLEASE LIST DIAGNOSES/DISORDERS YOUR CHILD HAS BEEN DIAGNOSED WITH:
Diagnosis
Provided by (list provider)
Date
CHECK ANY SPECIAL EQUIPMENT YOUR CHILD REQUIRES:
Crutches
Cane
Hearing aid
Nebulizer
Wheelchair
Walker
Communication Device
Oxygen
Leg brace
Glasses
Feeding tube
Arm/hand splints
Clinician Notes
Patient to fill out this column ONLY
SPEECH AND LANGUAGE HISTORY
PLEASE DESCRIBE ANY CONCERNS OR QUESTIONS YOU HAVE ABOUT YOUR CHILD’S
LANGUAGE OR SPEECH:
At what age did you child first show signs of difficulties with communication:
☐ No concerns
☐ Between birth and age 3
☐ Older than age 3
Communication skills include (check all that apply):
☐ Speech including:
☐ Single words
☐ Two-word phrases
☐ Short sentences
☐ Conversations
☐ To-and-fro/reciprocal conversation
☐ Question and answer type
☐ Engages in “social chat”
☐ Leading adults to preferred items
☐ Signs
☐ Pointing
☐ Picture Communication Systems
☐ Augmented Communication Systems (e.g., iPad, Dynavox)
Does your child engage in peculiar/abnormal speech patterns: (check all that apply)
☐
☐
☐
☐
Immediate Echolalia
☐ Delayed Echolalia
Pronoun reversal (I for Me) ☐ Odd tone/pitch
Odd rhythm
☐ Idiosyncratic words/phrases
Refers to self by own name (does not use “I”)
Clinician Notes
Patient to fill out this column ONLY
SCHOOL HISTORY
Early Identification or Early Intervention through Public School District?
☐ Home Care
☐Respite Care
☐ Day Care
☐ Preschool
***PLEASE COMPLETE SECTION BELOW***
☐ Public School ☐Private School
☐ Home School
*** PLEASE COMPLETE SECTION ON NEXT PAGE***
NAME OF CURRENT PRESCHOOL/HOME CARE/RESPITE CARE /DAY CARE:
LOCATION:
DAYS AND HOURS ATTENDED:
Monday
Tuesday
____to____
____to____
Wednesday
____to____
Thursday
____to____
Friday
____to____
Saturday
____to____
Sunday
____to____
NAME OF CURRENT PRESCHOOL/HOME CARE/RESPITE CARE /DAY CARE:
LOCATION:
DAYS AND HOURS ATTENDED:
Monday
Tuesday
____to____
____to____
Wednesday
____to____
Thursday
____to____
Friday
____to____
Saturday
____to____
Sunday
____to____
CHECK ANY SPECIAL EDUCATION SERVICES YOUR CHILD RECEIVES:
Current IEP
OT
Vision
Title I Math
Behavior disorders class
Resource
PT
Title I Reading
Speech/Language
Mainstreamed class
HAS YOUR CHILD HAD PSYCHOLOGICAL OR EDUCATIONAL TESTING?
YES
IF SO, WHAT WERE THE RESULTS?
DESCRIBE CURRENT ACADEMIC CONCERNS REPORTED BY CHILD’S TEACHERS:
NO
Clinician Notes
Patient to fill out this column ONLY
SCHOOL HISTORY
NAME OF CURRENT SCHOOL/PRESCHOOL:
TEACHER’S NAME:
CURRENT GRADE:
HAS YOUR CHILD BEEN RETAINED:
NO
YES
If yes, when:
PREVIOUS SCHOOLS YOUR CHILD HAS ATTENDED:
GRADE
SCHOOL
ACADEMIC PERFORMANCE
K
Below Ave.
Average
Above Ave.
1st
Below Ave.
Average
Above Ave.
2nd
Below Ave.
Average
Above Ave.
3rd
Below Ave.
Average
Above Ave.
4th
Below Ave.
Average
Above Ave.
5th
Below Ave.
Average
Above Ave.
6th
Below Ave.
Average
Above Ave.
7th
Below Ave.
Average
Above Ave.
8th
Below Ave.
Average
Above Ave.
9th
Below Ave.
Average
Above Ave.
10th
Below Ave.
Average
Above Ave.
11th
Below Ave.
Average
Above Ave.
12th
Below Ave.
Average
Above Ave.
CHECK ANY SPECIAL EDUCATION SERVICES YOUR CHILD RECEIVES:
Current IEP
OT
Vision
Title I Math
Behavior disorders class
Resource
PT
Title I Reading
Speech/Language
Mainstreamed class
HAS YOUR CHILD HAD PSYCHOLOGICAL OR EDUCATIONAL TESTING?
YES
IF SO, WHAT WERE THE RESULTS?
DESCRIBE CURRENT ACADEMIC CONCERNS REPORTED BY CHILD’S TEACHERS:
DESCRIBE CURRENT BEHAVIORAL CONCERNS REPORTED BY CHILD’S TEACHERS:
HAS YOUR CHILD SUSPENDED OR EXPELLED?
DATES AND REASONS?
YES
NO
NO
Clinician Notes
Patient to fill out this column ONLY
Behavior (please specify behavior)
Self-Injurious Behavior:
Onset (age)
Frequency
Once per week or less
Once Daily
1-3 per week
Multiple per day
Hourly
Examples:
Aggression:
Once per week or less
Once Daily
1-3 per week
Multiple per day
Hourly
Examples:
Property Destruction:
Once per week or less
Once Daily
1-3 per week
Multiple per day
Hourly
Examples:
Tantrums:
Once per week or less
Once Daily
1-3 per week
Multiple per day
Hourly
Examples:
Inappropriate Vocalizations:
Once per week or less
Once Daily
1-3 per week
Multiple per day
Hourly
Examples:
Pica (eating inappropriate objects):
Once per week or less
Once Daily
1-3 per week
Multiple per day
Hourly
Examples:
Elopement:
Once per week or less
Once Daily
1-3 per week
Multiple per day
Hourly
Examples:
Other:
Once per week or less
Once Daily
1-3 per week
Multiple per day
Hourly
Examples:
Other:
Once per week or less
Once Daily
1-3 per week
Multiple per day
Hourly
Examples:
Please describe any related injuries, consequences, or damage caused by above behaviors:
Please check any typical consequences implemented after problem behavior:
Verbal reprimand
Removal of preferred item/activity
Physical attention
Redirection
Time-out
Access to Preferred item/activity
Ignore
Other:
Escape from demands
Restraint
Clinician Notes
Patient to fill out this column ONLY
FAMILY HISTORY
PLEASE CHECK ANY OF THE FOLLOWING CONDITIONS THAT ARE OR HAVE BEEN PRESENT IN
THE CHILD’S IMMEDIATE OR EXTENDED BIOLOGICAL FAMILY:
SIBLINGS
Developmental Delay
ADHD
Mental Retardation
Learning Disability
Special Education
Cerebral Palsy
Blindness
Deafness
Seizures
Autism
Tics/Tourette’s
Enuresis (bedwetting)
Depression
Anxiety
Suicide
OCD
Schizophrenia
Sleep disorder
Alcoholism
Drug abuse
Migraine headaches
High blood pressure
Heart disease
Diabetes
Obesity
HIV or AIDS
Cancer
Dementia/Alzheimer’s
Genetic disorder
MOTHER
FATHER
MOTHER’S
RELATIVES
FATHER’S
RELATIVES
WHAT MY CHILD LIKES
CATEGORY
ITEM/ACTIVITY
TOYS
Toys with lights
Toys that spin
Toys with music
Toys that beep
Toys with sirens
Toys with car sounds
Dolls/action figures
Playing or trading
cards
Puzzles
Legos/blocks
Board games
Educational games
Toy vehicles
Arts & crafts
Stuffed animals
Dress up
ACTIVITY WITH
CHILD
OTHER
Electronic
Being spun
Swinging
Wrestling
Running
Being tickled
Pretend play
Being read to
Being sung to
Being told a story
Attention
Mirror
Shiny objects
Fuzzy objects
Playing in water
Bubbles
Lighted objects
Objects that spin
Cold things
Hot things
Video/computer
games
Music
Television/videos
FAVORITE
LIKES
DOES NOT
LIKE
MUNROE-MEYER INSTITUTE
NEBRASKA’S HEALTH SCIENCE CENTER
Date:
CENTER FOR AUTISM SPECTRUM DISORDERS
MUNROE-MEYER INSTITUTE
________________________
UNH#: ________________________
Patient Name:
________________________________
Date of Birth:
_______________________________
Please fully complete this form to ensure reimbursement from your insurance company.
Name of Primary Insurance Company:
Claims Mailing Address:
____________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Insurance Phone Number: __________________________________________________________________________
Policy #: _________________
Group #: _________________
Effective Date of Policy: _________________
Name of Insured: _________________________________________________________________________________
DOB:
___________________
Employer Name & Address:
SSN: _______________________
Relationship: __________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Name of Secondary Insurance Company:
Claims Mailing Address:
____________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Insurance Phone Number: __________________________________________________________________________
Policy #: __________________
Group #: __________________
Effective Date of Policy: _________________
Name of Insured: _________________________________________________________________________________
DOB:
___________________
Employer Name & Address:
SSN: _____________________
Relationship: ____________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Medicare #:
____________________________
Physicians Assignment:
Signature:
Medicaid #:
_______________________________
I hereby assign my medical benefits to which I may be entitled to be paid directly to my physician.
_____________________________________
Please check this box if you do not have any insurance coverage.
Date:
________________________
Submit by Email
985450 Nebraska Medical Center / Omaha, NE 68198-5450 / www.unmc.edu/mmi / 402-559-8863 / Fax: 402-559-5004
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