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Bridgeway Evaluation
I am seeking services in the state of Alabama.
Parent Information
Parents Name:
*
Email Address:
*
Home Phone:
*
Work Phone:
Cell Phone:
Address:
*
City:
*
State:
*
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Zip:
*
Person's Information
Person's Name:
*
Gender:
*
Male
Female
Birth Date:
*
Day
1
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Year
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Month
Jan
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Level of Education:
*
Too young to attend school
Grammar School
High School
College
Name of School:
Grade:
Ever been employed?:
*
Yes
No
Seeking Emplyment
Professional Diagnosis:
*
Autism Spectrum Disorder (DSM-5)
Asperger Syndrome (DSM-IV)
High Functioning Autism (DSM-IV)
PDD-NOS
Other
If other, describe:
Does this person know their diagnosis?:
*
Yes
No
Diagnosed by:
Profession:
Referred By:
Profession:
What is this person's current activities?:
*
Additional Notes:
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
Current Supports:
IEP
504
Vocational Rehabilitation
Psychologist
Psychiatrist
None
Other
Current Allergies:
Current Medications:
If you had to choose this person's top 3 current social skills goals, what would they be?:
*
I understand my information will remain confidential unless written permission is granted (
review confidentiality policy
).
I have read and reviewed the price list of services offered by Bridgeway (
review price list
).