Autism Evaluation
Revision 2.0,
November 2006
Procedural steps taken by the facilitator with the autistic
client:
Before the
procedure:
1. Verify the client can use EFT successfully.
2. Make sure the Liability and confidentiality form are
filled out for both the guardian and the facilitator.
3. Use the standard form attached to evaluate the degree of
autism in the client BEFORE the procedure.
4. Plan on the initial run being done with a facilitator
physically present, and with an ISPS staff member on the
phone.
5. Be sure the client understand that there may be
unexpected side effects, requiring interventions over the
next few days, and that they use this process at their own
risk.
6. Get a copy of the music required for the process.
Requirements
during the process:
1. Be in phone contact with an ISPS facilitator to run the
process (preferably in person).
2. We anticipate about an hour or two per client.
3. Prepare for strong abreactions.
Requirements
after the process:
1. Have the guardian fill out the standard evaluation form
AGAIN a week after the process is run.
2. Plan on at least three follow up healing session after
the week is over, spaced anywhere from a day to a week
apart.
3. Report any out of the ordinary reactions in the client.
4. Be available for any client calls (cell phone, etc.)
Autism Treatment Evaluation Checklist
(ATEC)
The following
questions are derived from the Autism Research Institute's
ATEC form. The full ATEC document can be seen at
www.autism.com/ari/atec/atec-online.htm.
If you are interested in finding out more about this
questionnaire, please check the Autism Research Institute
website www.autism.com for a
description of their procedures.
A. Information About Researcher and Project
Last Name / First Name of Researcher:
Name of data entry person [if different from above]:
Address 1:
Address 2:
City: , State: Zipcode:
Country [if outside U.S.]:
Telephone: Fax:
E-mail: <==Please enter your e-mail address
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B. Information Specific to Each ATEC/Person (Research
Subject)
Assessment Period [e.g., baseline, 1 week post, 1 month
post, etc.]:
Diagnosis: You may check more than one diagnosis.
Autism Asperger Syndrome PDD-NOS Landau-Kleffner Syndrome
Other
If you checked 'Other,' please specify:
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ATEC
Last Name / First Name of Child [or identification code]:
Sex of Child: Male Female
Age:
Date of Birth [format: mo/da/yr; e.g., 09/25/98]:
Today's Date [same format as above]:
Form Completed By: [first and last name]
Relationship: [e.g., mother, teacher]
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Please choose the appropriate letter for each item below.
I. Speech/Language/Communication
N = Not true S=Somewhat true V=Very true
1. Knows own name N S V
2. Responds to ‘No’ or ‘Stop’ N S V
3. Can follow some commands N S V
4. Can use one word at a time N S V
5. Can use 2 words at a time N S V
6. Can use 3 words at a time N S V
7. Knows 10 or more words N S V
8. Can use sentences with 4 or more words N S V
9. Explains what he/she wants N S V
10. Asks meaningful questions N S V
11. Speech tends to be meaningful/relevant N S V
12. Often uses several successive sentences N S V
13. Carries on fairly good conversation N S V
14. Has normal ability to communicate for his/her age N S V
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II. Sociability
N = Not descriptive S=Somewhat descriptive V=Very
descriptive
1. Seems to be in a shell - you cannot reach him/her N S V
2. Ignores other people N S V
3. Pays little or no attention when addressed N S V
4. Uncooperative and resistant N S V
5. No eye contact N S V
6. Prefers to be left alone N S V
7. Shows no affection N S V
8. Fails to greet parents N S V
9. Avoids contact with others N S V
10. Does not imitate N S V
11. Dislikes being held/cuddled N S V
12. Does not share or show N S V
13. Does not wave ‘bye bye’ N S V
14. Disagreeable/not compliant N S V
15. Temper tantrums N S V
16. Lacks friends/companions N S V
17. Rarely smiles N S V
18. Insensitive to other's feelings N S V
19. Indifferent to being liked N S V
20. Indifferent if parent(s) leave N S V
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III. Sensory/Cognitive Awareness
N = Not descriptive S=Somewhat descriptive V=Very
descriptive
1. Responds to own name N S V
2. Responds to praise N S V
3. Looks at people and animals N S V
4. Looks at pictures (and T.V.) N S V
5. Does drawing, coloring, art N S V
6. Plays with toys appropriately N S V
7. Appropriate facial expression N S V
8. Understands stories on T.V. N S V
9. Understands explanations N S V
10. Aware of environment N S V
11. Aware of danger N S V
12. Shows imagination N S V
13. Initiates activities N S V
14. Dresses self N S V
15. Curious, interested N S V
16. Venturesome - explores N S V
17. “Tuned in” - Not spacey N S V
18. Looks where others are looking N S V
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IV. Health/Physical/Behavior
N = Not a Problem MI=Minor Problem MO=Moderate Problem
S=Serious Problem
1. Bed-wetting N MI MO S
2. Wets pants/diapers N MI MO S
3. Soils pants/diapers N MI MO S
4. Diarrhea N MI MO S
5. Constipation N MI MO S
6. Sleep problems N MI MO S
7. Eats too much/too little N MI MO S
8. Extremely limited diet N MI MO S
9. Hyperactive N MI MO S
10. Lethargic N MI MO S
11. Hits or injures self N MI MO S
12. Hits or injures others N MI MO S
13. Destructive N MI MO S
14. Sound-sensitive N MI MO S
15. Anxious/fearful N MI MO S
16. Unhappy/crying N MI MO S
17. Seizures N MI MO S
18. Obsessive speech N MI MO S
19. Rigid routines N MI MO S
20. Shouts or screams N MI MO S
21. Demands sameness N MI MO S
22. Often agitated N MI MO S
23. Not sensitive to pain N MI MO S
24. “Hooked” or fixated on certain
objects/topics N MI MO S
25. Repetitive movements N MI MO S
Send completed evaluation to:
The Institute for the Study of Peak States
RR#1, Hornby Island, BC
V0R 1Z0
Canada