Autism Spectrum Screening Questionaire

This questionnaire is designed to help parents reflect on behaviors that may be associated with autism spectrum differences. It is not a diagnostic tool, but it may help identify whether further professional evaluation may be helpful.

First and Last name of Parent/Guardian

Phone

First and Last name of Child

Response Options & Points

Never = 0
Rarely = 1
Sometimes = 2
Often = 3
Very Often = 4

Instructions

Please answer the following questions based on your child’s typical behavior.

1. My child avoids or struggles to maintain eye contact during interactions.

2. My child prefers to play alone rather than engage with other children.

3. My child finds it difficult to understand facial expressions or tone of voice.

4. My child frequently repeats words or phrases.

5. My child becomes very upset when routines change.

6. My child has strong reactions to sounds, lights, textures, or smells.

7. My child engages in repetitive movements such as rocking or hand movements.

8. My child has very focused interests and talks about them frequently.

9. My child finds it difficult to start or maintain conversations.

10. My child struggles to express emotions or needs clearly.

11. My child has difficulty making or maintaining friendships.

12. My child becomes overwhelmed in crowded or noisy environments.

13. My child prefers very specific routines or patterns during daily activities.

14. My child has difficulty understanding other people’s feelings.

15. My child interacts more comfortably with adults than children their age.

Scoring

0 – 15 | Minimal Indicators

Your responses suggest few behaviors commonly associated with autism spectrum traits. Every child develops differently, but the answers provided do not currently suggest strong indicators of autism-related patterns.

Continue supporting your child's communication, emotional expression, and social development. If new concerns arise, consider speaking with a pediatrician or developmental professional.

16 – 30 | Mild Indicators

Some behaviors that can be associated with autism spectrum differences appear in your responses. These behaviors may also occur in children who are simply developing at different paces.

If these patterns are consistent or increasing, you may consider discussing them with a pediatrician, developmental specialist, or licensed professional for further guidance.

31 – 45 | Moderate Indicators

Your responses suggest several behaviors that may be consistent with autism spectrum characteristics. This does not confirm a diagnosis, but it may be beneficial to seek professional developmental screening or evaluation.

Early understanding and support can help children develop communication, emotional awareness, and coping skills.

46 – 60 | Strong Indicators

Your responses indicate multiple behaviors commonly associated with autism spectrum traits. A professional developmental assessment with a qualified healthcare provider or specialist is strongly recommended.

Early evaluation can help identify appropriate support strategies for your child's development.

Important Disclaimer

This screening questionnaire is for informational purposes only and does not diagnose autism or any developmental condition. If you have concerns about your child's development, please consult a licensed healthcare provider or developmental specialist.

Signature of Parent/Guardian

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