Autism Asperger Syndrome Consulting Group, LLC

Online Evaluation

Person's Name	Gender	Birth Date (mm/dd/yyyy)	Current Age
	Male Female
Level of Education	Name of School	Grade	Ever been employed?
Too young to attend school Grammar School High School College			Yes No Seeking Employment
Parents Names	Address	City	State, Zip

Home Phone (111-111-1111)	Work Phone (111-111-1111)	Cell Phone (111-111-1111)	Email Address

Professional Diagnosis	Diagnosed by	Referred By	Does this person know their diagnosis?
Asperger Syndrome High Functioning Autism PDD-NOS Other If other, describe	Profession	Profession	Yes No
What is this person's current activities?
1. 2. 3.
Weaknesses (check all that apply)
Theory of Mind Difficulty understanding someone's point of view Difficulty understanding emotions of self and others Thinks opinions are facts Difficulty understanding intentions of others Social Skills Difficulty maintaning a two-way conversation Talks excessively about topics Appears odd or different by peers Frequently blurts out inappropriate comments		Language Takes things literally Speaks "matter of fact" and often comes across negatively to others Often takes more time than normal to process language Difficulty putting thoughts down on paper Behavior Difficulty controlling behavior Has frequent meltdowns Difficulty thinking of multiple options to problems Difficulty ignoring a problem and moving on
If you had to choose this person's top 3 current social skills goals, what would they be?
1. 2. 3.