Social Communication Disorder Assessment Questionnaire Form
Use this form to review communication patterns, social interaction challenges, and related observations.
Assessment Context
Respondent Name or ID
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessment Context
*
Self-report
Caregiver report
Teacher report
Clinician observation
Other
Communication and Social Interaction Profile
Frequency of difficulty in communication and social interaction areas
*
Rows
Never
Rarely
Sometimes
Often
Almost Always
Back-and-forth conversation
1
2
3
4
5
Understanding implied meaning or sarcasm
6
7
8
9
10
Staying on topic
11
12
13
14
15
Adjusting communication to different people or settings
16
17
18
19
20
Interpreting facial expressions and body language
21
22
23
24
25
Maintaining relationships
26
27
28
29
30
Difficulty level across social communication skills
*
Rows
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Extreme Difficulty
Back-and-forth conversation
31
32
33
34
35
Understanding implied meaning or sarcasm
36
37
38
39
40
Staying on topic
41
42
43
44
45
Adjusting communication to different people or settings
46
47
48
49
50
Interpreting facial expressions and body language
51
52
53
54
55
Maintaining relationships
56
57
58
59
60
Overall impact of social communication difficulties
*
Minimal impact
1
2
3
4
Severe impact
5
1 is Minimal impact, 5 is Severe impact
Overall severity of social communication concerns
*
1
2
3
4
5
Functional Impact and Notes
Situations Where Communication Challenges Are Most Noticeable
Additional Notes or Examples
Would You Like Follow-Up or Next-Step Review?
*
Yes
No
Not sure
Submit Assessment
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