Qualtrics Survey | Qualtrics Experience Management

Caregiver Name (Person filling out this form):

Client Name:

Please read each question below and rate the behavior of your child or loved one using the following rating scale:

1 = Never 2 = Rarely 3 = Unsure 4 = Sometimes 5 = Always

N/A = Not Applicable

This information will be used by CARES staff to develop goals for skills that may be difficult to identify during clinic sessions.

Eating Habits

Please read each question below and rate the behavior of your child or loved one using the following rating scale:

1 = Never 2 = Rarely 3 = Unsure 4 = Sometimes 5 = Always
N/A = Not Applicable

This information will be used by CARES staff to develop goals for skills that may be difficult to identify during clinic sessions.

Eating Habits
	Never	Rarely	Unsure	Smetimes	Always	N/A
Eats food at a rapid pace	Never	Rarely	Unsure	Smetimes	Always	N/A
Takes large bites when eating	Never	Rarely	Unsure	Smetimes	Always	N/A
Stuffs large amounts of food into their cheeks or mouth before trying to swallow	Never	Rarely	Unsure	Smetimes	Always	N/A
Attempts to swallow before throughly chewing their food	Never	Rarely	Unsure	Smetimes	Always	N/A
Complies with requests to slow down or take smaller bites	Never	Rarely	Unsure	Smetimes	Always	N/A
Cuts their own food	Never	Rarely	Unsure	Smetimes	Always	N/A
Attempts to ingest non-edible items	Never	Rarely	Unsure	Smetimes	Always	N/A
Eats a variety of foods	Never	Rarely	Unsure	Smetimes	Always	N/A

Has had a choking incident

Eating Habits Additional Information

Habits in Public Places:

Habits in Public Places:
	Never	Rarely	Unsure	Sometimes	Always	N/A
Approaches unfamiliar people	Never	Rarely	Unsure	Sometimes	Always	N/A
Talks to unfamiliar people without being prompted	Never	Rarely	Unsure	Sometimes	Always	N/A
Hugs unfamiliar people without being prompted	Never	Rarely	Unsure	Sometimes	Always	N/A
Holds the hand of an unfamiliar person without being prompted	Never	Rarely	Unsure	Sometimes	Always	N/A
Takes items from unfamiliar people when they are offered	Never	Rarely	Unsure	Sometimes	Always	N/A
Walks away from familiar persons when in public places	Never	Rarely	Unsure	Sometimes	Always	N/A
Attempts to pet unfamiliar animals without asking permission	Never	Rarely	Unsure	Sometimes	Always	N/A

Habits in Public Places Additional Information:

Habits at Home:

Habits at Home:
	Never	Rarely	Unsure	Soemtimes	Always	N/A
Walks outside without permission when at home	Never	Rarely	Unsure	Soemtimes	Always	N/A
Walks with scissors/sharp objects pointed towards the floor	Never	Rarely	Unsure	Soemtimes	Always	N/A
Keeps scissors closed when they are not using them	Never	Rarely	Unsure	Soemtimes	Always	N/A
Attempts to touch hot surfaces, such as a stovetop or a burner	Never	Rarely	Unsure	Soemtimes	Always	N/A
Uses or attempts to use cleaning products or toiletries	Never	Rarely	Unsure	Soemtimes	Always	N/A
Attempts to ingest cleaning products, medications (other than when needed), or toiletries	Never	Rarely	Unsure	Soemtimes	Always	N/A
Indicates when they are in pain or don't feel well	Never	Rarely	Unsure	Soemtimes	Always	N/A
Indicates the specific pain or discomfort they are having	Never	Rarely	Unsure	Soemtimes	Always	N/A
Pulls on large heavy objects (such as bookshelf or TV stand)	Never	Rarely	Unsure	Soemtimes	Always	N/A
Leans on large heavy objects (such as a bookshelf or TV stand)	Never	Rarely	Unsure	Soemtimes	Always	N/A

Habits at Home Additional Information

Traffic Safety

Traffic Safety
	Never	Rarely	Unsure	Sometimes	Always	N/A
Looks both ways before crossing the street	Never	Rarely	Unsure	Sometimes	Always	N/A
Waits until cars are either stopped or at a safe distance before attempting to cross the street	Never	Rarely	Unsure	Sometimes	Always	N/A
Attempts to take off their own seat belt while riding in the car	Never	Rarely	Unsure	Sometimes	Always	N/A
Complies with instructions during car rides	Never	Rarely	Unsure	Sometimes	Always	N/A
Hold parent or adult hand when walking	Never	Rarely	Unsure	Sometimes	Always	N/A

Traffic Safety Additional Information

Water Safety

Water Safety
	Never	Rarely	Unsure	Sometimes	Always	N/A
Indicates when water is too hot or cold for bathing or washing hands	Never	Rarely	Unsure	Sometimes	Always	N/A
Adjusts water temperature without assistance	Never	Rarely	Unsure	Sometimes	Always	N/A
Attempts to get into water without adult supervision	Never	Rarely	Unsure	Sometimes	Always	N/A
Is able to swim	Never	Rarely	Unsure	Sometimes	Always	N/A

Water Safety Additional Information

Peer Interactions

Peer Interactions
	Never	Rarely	Unsure	Sometimes	Always	N/A
When told by a peer to do something, complies	Never	Rarely	Unsure	Sometimes	Always	N/A
Is motivated by attention from peers	Never	Rarely	Unsure	Sometimes	Always	N/A
Interacts with same-age peers inappropriately or offensively	Never	Rarely	Unsure	Sometimes	Always	N/A
Peers interact with them inappropriately or offensively	Never	Rarely	Unsure	Sometimes	Always	N/A

Peer Interactions Additional Information

Internet Usage

Internet Usage
	Never	Rarely	Unsure	Sometimes	Always	N/A
Utilizes social networking	Never	Rarely	Unsure	Sometimes	Always	N/A
When online, clicks pop-up windows or advertisements	Never	Rarely	Unsure	Sometimes	Always	N/A
Shares inappropriate information on the internet (personal, financial)	Never	Rarely	Unsure	Sometimes	Always	N/A

Internet Usage Additional Information

Privacy

Privacy
	Never	Rarely	Unsure	Sometimes	Always	N/A
Closes the bathroom/stall door prior to using the restroom	Never	Rarely	Unsure	Sometimes	Always	N/A
Only dresses in areas that are private/closed	Never	Rarely	Unsure	Sometimes	Always	N/A
Can identify adults that can help bathe/in the bathroom	Never	Rarely	Unsure	Sometimes	Always	N/A
Can identify what their private parts are	Never	Rarely	Unsure	Sometimes	Always	N/A
Can identify people that are allowed to talk about or look at their private parts	Never	Rarely	Unsure	Sometimes	Always	N/A
Will allow inappropriate people to talk about or look at their private parts	Never	Rarely	Unsure	Sometimes	Always	N/A
Can report inappropriate/hurtful/uncomfortable situations to an adult	Never	Rarely	Unsure	Sometimes	Always	N/A

Privacy Additional Information

Personal Identification Information - The individual can identify:

Personal Identification Information - The individual can identify:
	Never	Rarely	Unsure	Sometimes	Always	N/A
Home address	Never	Rarely	Unsure	Sometimes	Always	N/A
Home phone number	Never	Rarely	Unsure	Sometimes	Always	N/A
Can identify adults that can help bathe/in the bathroom	Never	Rarely	Unsure	Sometimes	Always	N/A
Can identify what their private parts are	Never	Rarely	Unsure	Sometimes	Always	N/A
Can identify people that are allowed to talk about or look at their private parts	Never	Rarely	Unsure	Sometimes	Always	N/A
Will allow inappropriate people to talk about or look at their private parts	Never	Rarely	Unsure	Sometimes	Always	N/A
Can report inappropriate/hurtful/uncomfortable situations to an adult	Never	Rarely	Unsure	Sometimes	Always	N/A

Personal Identification Information Additional Information

Safety Skills

Safety Skills
	Never	Rarely	Unsure	Sometimes	Always	N/A
Will scream for help	Never	Rarely	Unsure	Sometimes	Always	N/A
Displays fear behaviors towards unfamiliar people	Never	Rarely	Unsure	Sometimes	Always	N/A
Displays fear behavior towards other animals	Never	Rarely	Unsure	Sometimes	Always	N/A
Displays fear behavior in unfamiliar places	Never	Rarely	Unsure	Sometimes	Always	N/A
Can identify community helpers in a store (e.g., clerk/employee)	Never	Rarely	Unsure	Sometimes	Always	N/A
Can identify community helpers in public (e.g., policeman)	Never	Rarely	Unsure	Sometimes	Always	N/A
Will approach community helpers	Never	Rarely	Unsure	Sometimes	Always	N/A
Responds to "stop" by stopping feet and looking back at the person	Never	Rarely	Unsure	Sometimes	Always	N/A
Will wait near an adult when told	Never	Rarely	Unsure	Sometimes	Always	N/A

Safety Skills Additional Information

Risk Prevention Checklist

Risk Prevention Checklist
	Yes	Maybe	No
Child medical and safety bracelet (and tattoos)	Yes	Maybe	No
Locks on doors	Yes	Maybe	No
Selt belt locks	Yes	Maybe	No
Alarms on doors and windows	Yes	Maybe	No
Lock/fence around pool or water	Yes	Maybe	No
Enrolled in child ID program	Yes	Maybe	No
Child tracking device	Yes	Maybe	No
Medications are locked up	Yes	Maybe	No
First aid kits available in home or car	Yes	Maybe	No
Non-emergency has been contacted and first responders have been notified there is an individual with special needs in the home and a picture is provided	Yes	Maybe	No

Parent Tool-kit: Please check the following items you would like:

Parent Tool-kit: Please check the following items you would like:
	Yes	No
Danger stickers	Yes	No
Poison stickers	Yes	No
Stop sign stickers	Yes	No
Teach them to state their location on a cell-phone	Yes	No
Smoke emulation to practice for fires	Yes	No
Elopement plan (if elopement occurs... the following people do this _____)	Yes	No