自闭症社交技巧清单.pdf

Autism Social Skills Profile Scott Bellini Child’s Name:______________________________________________________________________ FIRST MIDDLE LAST Birthdate: ____________ Age: _____ Sex: GFemale GMale Today’s Date: ____________ MO. DAY YEAR MO. DAY YEAR School: _______________________________________________________________ Grade: ______ Your Name: ______________________________________________________________________ FIRST MIDDLE LAST Relationship to Child: GMother GFather GGuardian GOther ______________________ Street Address: ____________________________________________________________________ City: ________________________________________ State: ________ Zip: ________________ Phone: ( ) ________________________________________________________________ The following phrases describe skills or behaviors that your child might exhibit dur- ing social interactions or in social situations. Please rate HOW OFTEN your child exhibits each skill or behavior independently, without assistance from others (i.e., without reminders, cueing and/or prompting). You should base your judgment on your child’s behavior over the last 3 months. Please use the following guidelines to rate your child’s behavior: Circle N if your child never or almost never exhibits the skill or behavior. Circle S if your child sometimes or occasionally exhibits the skill or behavior. Circle O if your child often or typically exhibits the skill or behavior. Circle V if your child very often or always exhibits the skill or behavior. Please do not skip any items. If you are unsure of an item, please provide your best estimate. You