Support requirements Step 1 of 2 50% IntroductionThis form asks questions about your child's preferences, interests, skills and requirements so that we can understand how best to support them.Child's name(Required)Communicates wants/needs Verbally With sign / compic With gesture When prompted Understands instructions(Required) In most situations Familiar instructions in unfamiliar environments Familiar instructions in familiar environments Rarely Level of support required to:(Required)IndependentlyWith verbal promptWith verbal & visual promptWith co-active helpUndressWash handsWash him/herselfBrush teethBrush hairChoose clothingDressToilet independently - day timeToilet independently - night timeFeed him/herself with spoonFeed him/herself with forkUse knife and fork to cutMy child:(Required)Most timesSometimesRarelyNeverLikes to be aloneLikes company of other childrenLikes company of adultsSleeps through the nightBedtimeUsual bedtime(Required)Usual waketime(Required)Any bedtime routine?Food and drinkWhat food and drink does your child like for breakfast?(Required)What food and drink do they like for lunch?(Required)What food and drink do they like for dinner?(Required)Does your child dislike any food or drink?(Required) BehavioursDoes your child display any repetitive behaviours, or have any obsessions?(Required)What happens if you interrupt them when they are engaged in a repetitive activity?(Required)Could any of these behaviours potentially cause harm to themselves or others?(Required)What strategies do you use at home to support your child?(Required)ActivitiesHow well can your child:Very wellNeeds some supportNeeds lots of supportNot well at allRide a bikeSwimCross the roadWalk with a groupBe out in the community (shops etc)What activities does your child enjoy?(Required)What activities, if any, do they dislike?Are you currently implementing any programs with your child? Please describeOther informationIs there anything else you would like Mansfield Autism to know?
