Autism Treatment Evaluation Checklist
Please complete this checklist to help evaluate the effectiveness of autism treatment interventions. Answer each item as accurately as possible.
Child's Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Evaluator's Name
*
First Name
Last Name
Relationship to Child
*
Parent/Guardian
Therapist
Teacher
Other
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Communication Skills
*
Rows
Never
Rarely
Sometimes
Often
Always
Responds to name
1
2
3
4
5
Uses words to express needs
6
7
8
9
10
Understands simple instructions
11
12
13
14
15
Initiates conversation
16
17
18
19
20
Sociability
*
Rows
Never
Rarely
Sometimes
Often
Always
Makes eye contact
21
22
23
24
25
Plays with peers
26
27
28
29
30
Shows interest in others
31
32
33
34
35
Shares enjoyment
36
37
38
39
40
Sensory / Cognitive Awareness
*
Rows
Never
Rarely
Sometimes
Often
Always
Responds to sounds
41
42
43
44
45
Aware of surroundings
46
47
48
49
50
Shows curiosity
51
52
53
54
55
Recognizes familiar people
56
57
58
59
60
Health / Physical Behavior
*
Rows
Never
Rarely
Sometimes
Often
Always
Sleeps well
61
62
63
64
65
Eats a variety of foods
66
67
68
69
70
Has regular bowel movements
71
72
73
74
75
Displays repetitive behaviors
76
77
78
79
80
Please provide any additional comments or observations.
Submit Evaluation
Should be Empty: