Healthcare Autism Assessment Form

HEALTHCARE AUTISM ASSESSMENT FORM

Patient Information

Date of Birth:    Gender: Male Female Other

Parent / Guardian (if patient is a minor)

Insurance / Referral

Assessment Details

Assessment Date:    Assessor Name:

Primary reason for assessment:

Developmental & Medical History

Educational / Behavioral Information

Screening & Assessment Tools Used

ADOS-2    CARS-2    M-CHAT    SRS-2    Clinical Interview / Observation

Findings & Clinical Impression

Recommendations & Care Plan

Confidentiality, Authorization & Acknowledgments

I authorize the clinician and staff to conduct the autism assessment as described above. I understand that the assessment process may include clinical interview, standardized testing, direct observation, and review of records. I acknowledge that the results will be documented in the patient's clinical record and used to inform diagnostic impressions and recommendations.

I understand that information contained in my or my child's record is confidential and will not be released without my written authorization except as required or permitted by law. Exceptions to confidentiality include identified risk of harm to self or others, suspected abuse or neglect, and other legal requirements. I understand that requests for release of records require a separate signed authorization unless expressly authorized below.

I authorize the assessor to:
Share results with referring provider(s)
Share results with school or educational team as needed
Audio/video record the assessment for clinical use

I understand that I may revoke this authorization in writing at any time, except where the action has already been taken in reliance on this authorization. Revocation must be submitted in writing to the clinician. This authorization will expire on the date indicated below or one year from the date of signature if no date is provided.

Patient / Guardian Acknowledgment

By signing below I certify that I have read and understand the information provided in this form, have had an opportunity to ask questions, and consent to the assessment and the disclosures specified above. I understand my rights regarding confidentiality and the limits thereof.

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