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DOES YOUR CHILD DISPLAY POSSIBLE SIGNS OF AUTISM?

To help families determine whether a child is showing signs of being on the
autism spectrum, we've developed a screener tool featuring a series of
true-false statements that should only take a few minutes to complete. Results
are immediate.












Screening Questions


My child is rarely sensitive to sounds and does not cover his/her ears when
upset.
TrueFalse

My child almost always turns to look at me when I address him or her.
TrueFalse

My child rarely holds items close to his or her eyes or looks at things from
unusual angles
TrueFalse

My child does not like to stare excessively at lights, mirrors, ceiling fans or
falling objects.
TrueFalse

My child is a good eater and eats a wide variety of foods.
TrueFalse

My child never flaps his/her hands or becomes rigid when excited or angry.
TrueFalse

My child has good coordination and has no difficulty with age-appropriate,
fine-motor tasks
TrueFalse

My child points with his or her index finger to draw my attention to objects.
TrueFalse

My child usually seeks out other children his or her own age when they are near.
TrueFalse

My child would rather play with other children than do his or her own thing.
TrueFalse

My child almost always looks me in the eye when I talk to him or her.
TrueFalse

My child can easily imitate actions, words and facial expressions.
TrueFalse

My child can label and request most objects and actions.
TrueFalse

My child rarely insists that things be done the way they are usually done.
TrueFalse

My child rarely insists that things be done his or own way.
TrueFalse

My child rarely needs routine and is very flexible with unplanned changes.
TrueFalse

My child is fairly compliant and usually follows my directions.
TrueFalse

My child easily follows verbal instructions and directions.
TrueFalse

My child does not rock, jump, spin or move around excessively.
TrueFalse

My child follows rules we have discussed, even when I am not around.
TrueFalse


Child/Parent Information





*Child’s Full Name:



*Child’s Date of Birth:
Select a date for
Format: Dec 31, 2024

*Parent/Guardian’s First Name:



*Parent/Guardian’s Last Name:



*Email:



*Phone Number:



Preferred Method of Contact:
--None--PhoneTextEmailNo Preference

*Child's Street Address:



*City:



Apartment/Suite #:



*State:
*
--None--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew
HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth
DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth
DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

*Zip:



Preferred Caravel Center Location:
--None--IA: AnkenyIA: BettendorfIA: Cedar RapidsIA: DavenportIA: DubuqueIA: Iowa
CityIA: UrbandaleID: BoiseID: Coeur dAleneID: MeridianID: NampaIL: ChicagoIL:
Crystal LakeIL: ElginIL: GenevaIL: RockfordIL: Rolling MeadowsIL:
Warrenville/NapervilleIN: DyerIN: MunsterMN: AnokaMN: DuluthMN: LakevilleMN:
MankatoMN: MoorheadMN: PlymouthMN: RochesterMN: ShakopeeMN: St. CloudMN: White
Bear LakeMN: WoodburyMO: OakvilleMO: Weldon SpringWA: Federal WayWA:
KennewickWA: SpokaneWA: TacomaWI: AppletonWI: Bellevue/Green BayWI: BeloitWI:
BrillionWI: BrookfieldWI: De PereWI: East MadisonWI: Eau ClaireWI: Fond du
LacWI: FranklinWI: Green Bay: Counseling and DiagnosticsWI: Howard/Green BayWI:
JanesvilleWI: KenoshaWI: KimberlyWI: La CrosseWI: Lake GenevaWI: Menomonee
FallsWI: MequonWI: Mequon: Counseling and DiagnosticsWI: Mitchell
St./MilwaukeeWI: OshkoshWI: PewaukeeWI: SheboyganWI: WausauWI: West Madison

*Insurance:
Private InsuranceMedicaid or State-fundedSelf-fundedOther
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