Autism Private Assessment Intake Questionnaire Form
Complete this intake questionnaire for an autism private assessment. The form uses a calm, premium SaaS-style design and asks for the information needed to arrange and prepare for the assessment.
Client Information
Client full name
*
First Name
Middle Name
Last Name
Preferred pronouns
She/her
He/him
They/them
Prefer not to say
Prefer to self-describe
Date of birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/guardian name (if applicable)
Assessment Background
Main reason for seeking an autism private assessment
*
How did you hear about our service?
*
Please Select
GP or doctor
School or education provider
Therapist or counselor
Friend or family
Online search
Social media
Other
Who is this assessment for?
*
Myself
My child or dependent
Communication and Support Needs
Communication and Support Preferences
*
Rows
Preferred
Needs Support
Verbal communication
1
2
Written communication
3
4
Visual supports (e.g., pictures, prompts)
5
6
Extra processing time
7
8
Reduced sensory stimulation
9
10
Breaks during the appointment
11
12
Additional accommodations or communication notes
Scheduling and Contact Details
Best email address
*
example@example.com
Best phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred appointment date/time
*
Submit Intake
Should be Empty: