COMPASS Consultation Action Plan: Step A

Abstract

Overview: This chapter covers Step A of the COMPASS Consultation Action Plan, which is conducted prior to the consultation. This information will inform the framework for the student’s personalized COMPASS profile.

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Overview: This chapter covers Step A of the COMPASS Consultation Action Plan, which is conducted prior to the consultation. This information will inform the framework for the student’s personalized COMPASS profile.

In this chapter, we describe Step A, the first of two procedural steps, of a COMPASS Consultation Action Plan. This includes:

• 1. Gathering information about the student from consultant observations and from the caregiver and teacher reports using the COMPASS Challenges and Supports Form for Caregivers and Teachers.

• 2. Completing the COMPASS Challenges and Supports Joint Summary Form (JSF).

There are a total of two steps to the COMPASS Consultation Action Plan that help the consultant prepare for the collaborative consultation (see Table 6.1). In Step A, which is explained in this chapter, the consultant gathers current information about the student from teachers and caregivers before the consultation begins. Then, in Step B, which is outlined in Chap. 7, the information gathered in the first step is shared, giving all participants a common understanding of the student’s current personal and environmental challenges and the personal and environmental supports necessary for success. Then, the consultant, caregiver, and teacher prioritize goals, write measurable objectives, and develop the teaching plan and identify environmental supports for each objective. Forms and handouts that represent Steps A and B of the action plan are provided at the end of these two chapters.

Table 6.1 COMPASS consultation action plan for students with autism

Subsequent to COMPASS consultation is teacher coaching. These procedures are discussed in Chap. 8—Coaching Sessions: Implementing Plans and Monitoring Progress.

Step A: Activities Conducted Prior to a COMPASS Consultation

The primary activity in this chapter sets the stage for developing the educational foundation for the student and is the first step described in the COMPASS Consultation Action Plan for Students with Autism. Step A helps the consultant prepare for the collaborative consultation by providing forms especially developed for students with ASD for completion by caregivers and teachers so that current information is gathered about the student.

There are two parts to Step A:

Gather Information About the Student Using COMPASS Challenges and Supports Form for Caregivers and Teachers

Gathering information about the student can be completed in several ways, such as the consultant conducting a direct assessment and observation and the consultant obtaining information from teachers and caregivers using rating scales and questionnaires.

Consultant Observations

The assessment process to obtain consultation observations includes required activities and recommended activities. Although we recommend that the functional assessment include the consultant having direct interactions with the student, it may not always be feasible to conduct an observation or evaluation of the student prior to consultation. Therefore, information can also be gathered from parents/caregivers, teachers, therapists, record review, observations, and other means such as videotape review. In our earlier consultation work, we asked teachers and caregivers to videotape the student during structured and unstructured activities at school (and home if possible) that depicted the student’s typical communication, social, and learning skills. Although this was very helpful, an obvious pitfall was that it did not allow us to interact with the student directly.

Necessary consultant assessment activities include the following:

• Review of previous medical, psychological, language, and other assessment reports.

• Review the current IEP for social, communication, and learning skill objectives and measurability of objectives (see Chap. 5 for more information on IEPs).

• Review videotapes or conduct observations of the student during a structured work activity in the classroom or with the consultant.

• Review videotapes or conduct observations of the student during unstructured activities, such as free play, recess, and lunch.

Consultant assessment activities that are not necessary but are recommended include:

• Conduct a direct assessment of the student’s developmental, adaptive behavior, and cognitive skills using standardized measures.

• Conduct direct assessment of the student’s social, communication, and learning skills from criterion-referenced measures or observation.

A Consultant Assessment Checklist is provided in the forms section at the end of the chapter, which can help facilitate the collection of the consultant observations. In our research, we have found that direct student interactions are valuable because they allow the consultant not only to conduct his or her own functional assessment of the student’s cognitive, problem solving, social, language, and learning skills, but also to examine how the student responds using various environmental supports. For example, during the assessment, the consultant can use a work-reward routine and a visual schedule. It is helpful to know if the student understands the use of visuals for these purposes and whether student engagement and motivation during assessment can be enhanced. The consultant can also set up the assessment to elicit certain learning skills (see item 8, “Learning Skills,” in the COMPASS Challenges and Supports Form for Caregivers and Teachers) to record how well the student understands and demonstrates starting a work task, finishing a work task, asking for help, etc.

Caregiver and Teacher Reports

To help gather information that is representative of the student at home, in the community, and at school, the consultant will present the COMPASS Challenges and Supports Form for Caregivers and Teachers to the caregiver and the teacher to fill out separately. This form asks the caregiver and the teacher to indicate the child’s adaptive skills, problem behaviors, social and play skills, communication skills, sensory challenges, sensory supports, learning skills, environmental challenges and supports, and to list concerns that interfere with the child’s success. Family members complete one set, and the student’s primary special education teacher completes a set. If the student is in a general education classroom, receives speech and language therapy or occupational therapy, or receives instruction from other school personnel, it is recommended that their input be sought and added. For example, the occupational therapist can provide information on the student’s fine and gross motor skills and sensory issues. The speech language pathologist has information regarding the student’s communication strengths and weaknesses and pragmatic difficulties that can be shared.

Complete COMPASS Challenges and Supports Joint Summary Form

Once the parent/caregiver and teacher complete their sets of the COMPASS Challenges and Support Form for Caregivers and Teachers and return them to the consultant prior to the consultation, the consultant then summarizes the information in a COMPASS Challenges and Support Joint Summary Form. At the first consultation (Step B), the consultant will provide this summary to the caregivers and teachers. This summary organizes the information and also ensures that all participants have a common understanding of the student’s personal and environmental challenges, as well as the student’s personal and environmental strengths.

Directions on completing the three COMPASS forms discussed in this chapter are provided with the forms.

Appendices

Appendix A Consultant Assessment Checklist

It is necessary for the consultant to obtain information directly or indirectly about the child. Activities that are necessary and those that are recommended but not required are as follows:

Necessary Activities

• A. Gather most recent assessment information and provide the following details:

  Area evaluated	Date of evaluation	Findings
  Medical
  Psychological
  Receptive and expressive language
  Fine and gross motor
  Adaptive behavior

• B. Review current IEP for social, communication, and learning skill objectives and measurability of objectives (see Chap. 8 for more information on IEPs).

  Domain	IEP objective
  Social
  Communication
  Learning skills
  Other

• C. Review videotape or conduct observation of student during a structured work activity in the classroom or with the consultant, observe how the student initiates and responds, communicates, and works independently.

  Activity	Description and length	Observations

• D. Review videotape or conduct observation of the student during unstructured activities, such as free play, recess, and lunch and observe how the student initiates and responds, communicates with adults and peers and how they respond to him/her.

  Activity	Description and length	Observations

Recommended But Not Required

• A. Conduct direct assessment of child’s developmental, adaptive behavior, and cognitive skills using standardized measures.

  Assessment tool	Skills evaluated	Results and observations

• B. Conduct direct assessment of child’s social, communication, and learning skills from criterion-referenced measures or observation.

  Assessment tool	Skills evaluated	Results and observations

Appendix B COMPASS Challenges and Supports Form for Caregivers and Teachers/Service Providers

Child’s/Student’s Name: _____________________________________________ Date: ______________

Your Name: _________________________________

Your Relationship to Child: _____________________

Likes, Strengths, Frustrations and Fears

The information you provide is vital in understanding how to build a competency model for your child/student.

Directions: Please list all the activities, objects, events, people, food, topics, or anything that is preferred by your child/student. These help identify ways to motivate and skills on which to build.

Directions: Please list and describe the fears and frustrations of your child/student. Please be specific about the situations in which these occur and the behavior your child/student shows.

Adaptive Skills

Directions: Please answer each item using the scale as it presently applies to your child/student, with “1” meaning “not at all a problem” and “4” meaning “very much a problem.” Add examples and notes as desired.

Self-management	Not at all			Very much
Performing basic self-care independently (such as toileting, dressing, eating, using utensils)	1	2	3	4
Entertaining self in free time	1	2	3	4
Changing activities—transitioning	1	2	3	4
Sleeping	1	2	3	4
Responding to others
Following 1 or 2 step direction	1	2	3	4
Accepting “no”	1	2	3	4
Answering questions	1	2	3	4
Accepting help	1	2	3	4
Accepting correction	1	2	3	4
Being quiet when required	1	2	3	4
Understanding group behaviors
Coming when called to group	1	2	3	4
Staying within certain places—lines, circles, chairs, desks	1	2	3	4
Participating with the group	1	2	3	4
Talking one at a time	1	2	3	4
Picking up, cleaning up, straightening up, putting away	1	2	3	4
Understanding community expectations
Understanding who is a stranger	1	2	3	4
Going to places in the community (place of worship, stores, restaurants, malls, homes)	1	2	3	4
Understanding safety (such as streets, seat belts)	1	2	3	4
Managing transportation (Cars/buses)	1	2	3	4

Problem Behaviors*

Directions: Please answer each item on the scale of 1–4 as it presently applies to your child/student, with “1” meaning “not at all a problem” and “4” meaning “very much a problem.”

		Not at all			Very much
1.	Acting impulsively, without thinking	1	2	3	4
2.	Hitting or hurting others	1	2	3	4
3.	Damaging or breaking things that belong to others	1	2	3	4
4.	Screaming or yelling	1	2	3	4
5.	Having sudden mood changes	1	2	3	4
6.	Having temper tantrums	1	2	3	4
7.	Having a low frustration tolerance; becoming easily angered or upset	1	2	3	4
8.	Crying easily	1	2	3	4
9.	Being overly quiet, shy, or withdrawn	1	2	3	4
10.	Acting sulky or sad	1	2	3	4
11.	Being underactive or lacking in energy	1	2	3	4
12.	Engaging in behaviors that may be distasteful to others, such as nose-picking or spitting	1	2	3	4
13.	Touching him/herself inappropriately	1	2	3	4
14.	Engaging in compulsive behaviors; repeating certain acts over and over	1	2	3	4
15.	Hitting or hurting him/herself	1	2	3	4
16.	Becoming overly upset when others touch or move his/her belongings	1	2	3	4
17.	Laughing/giggling at inappropriate times	1	2	3	4
18.	Ignoring or walking away from others during interactions or play	1	2	3	4
19.	Touching others inappropriately	1	2	3	4
20.	Engaging in unusual mannerisms such as hand-flapping or spinning	1	2	3	4
21.	Having to play or do things in the same exact way each time	1	2	3	4
22	Having difficulty calming him/herself down when upset or excited	1	2	3	4
23.	Other: _______________________________________	1	2	3	4

*Items are based on the Triad Social Skills Assessment

Add comments:

Social and Play Skills

Directions: Please rate the following statements on a scale of 1–4, with 1 meaning “not very well” and 4 meaning “very well.” Please answer each question first in terms of the child’s interactions with adults, and then with children.

How well does the child/student		With adults				With children
Social awareness		Not Very well			Very well	Not Very well			Very well
1.	Look toward a person who is talking to him/her	1	2	3	4	1	2	3	4
2.	Accept others being close to him/her	1	2	3	4	1	2	3	4
3.	Watch people for extended periods of time	1	2	3	4	1	2	3	4
4.	Respond to another person’s approach by smiling or vocalizing	1	2	3	4	1	2	3	4
5.	Initiate interactions for social reasons	1	2	3	4	1	2	3	4
Joint attention skills
6.	Look at something another person points to	1	2	3	4	1	2	3	4
7.	Show something to a person and look for person’s reaction	1	2	3	4	1	2	3	4
8.	Point at an object or event to direct another person’s attention to share enjoyment	1	2	3	4	1	2	3	4
9.	Share smile by looking back and forth between object and person	1	2	3	4	1	2	3	4
Imitation
10.	Imitate sounds another person makes	1	2	3	4	1	2	3	4
11.	Imitate what another person does with an object (such as a person makes toy airplane fly, the child repeats action)	1	2	3	4	1	2	3	4
12.	Imitate body movements of others (such as clap when others clap, play Simon Says)	1	2	3	4	1	2	3	4
13.	Imitate and expand upon other’s actions with toys (such as peer beats drum, child beats drum and also starts to march)	1	2	3	4	1	2	3	4
Play		Not Very well			Very well	Not Very well			Very well
14.	Take turns within familiar routines (such as rolls a ball back and forth)	1	2	3	4	1	2	3	4
15.	Share toys	1	2	3	4	1	2	3	4
16.	Play interactively around a common theme	1	2	3	4	1	2	3	4
17.	Repair breakdowns during interactions (such as the child repeats or changes own behavior when other person seems confused or ignores)	1	2	3	4	1	2	3	4
18.	Pretends to do something or be something (such as that a plate is a hat by putting it on, to be a policeman, to have a tea party, that a doll is a teacher)	1	2	3	4	1	2	3	4

Communication Skills

Directions: Please describe how your child/student lets you know the following communicative messages through words or actions. Indicate any method your child/student uses to indicate the message. For example, if s/he does not use words, but instead takes you by the hand to request juice, you would write that he takes you by the hand. If your child/student uses words, write what s/he says; or if a combination of ways are used, describe all ways.

Making Requests

1. Food

2. Objects

3. An activity

4. To use the toilet

5. Attention

6. Help

7. To play

8. Information

9. A choice

Expressing Refusals

1. “Go away”

2. “No, I won’t do it” or “I don’t want it”

3. “I want to be finished” or “I want to stop doing this”

Expressing Thoughts

1. Greeting to others

2. Comments about people/environment

3. Confusion or “I don’t know”

4. Comments about errors or things wrong

5. Asks about past or future events

6. Agreement

Expressing Feelings

1. Angry/mad/frustrated

2. Pain/illness/hurt

3. Happy/excited

4. Hurt feelings/upset

5. Afraid

6. Sad

Sensory Challenges

Directions: Please put a check before each statement that describes your child/student.

Sound/Auditory

□Has been diagnosed with hearing problem at some time	□Fails to listen or pay attention to what is said to him/her
□Reacts to unexpected sounds	□Talks a great deal
□Fears some noises	□Own talking interferes with listening
□Distracted by certain sounds	□Overly sensitive to some sounds
□Confused about direction of sounds	□Seeks out certain noises or sounds
□Makes self-induced noises	□Other: _____________________________

Taste

□Has an eating problem	□Explores environment by tasting
□Dislikes certain foods and textures	□Puts most things in his/her mouth
□Will only eat a small variety of foods	□Constant chewing on something
□Tastes/eats nonedibles	□Other:_____________________________

Sight/Vision

□Has trouble discriminating shapes, colors	□Excited by vistas and open spaces
□Is sensitive to light—squints, wants to wear hats or sunglasses	□Hesitates going up or down stairs, curbs, or climbing equipment
□Has trouble following with eyes	□Upset by things looking different (spills, spots)
□Does not make much eye contact	□Makes decisions about food, clothing, objects by sight
□Is distracted by some/too much visual stimuli	□Closely examines objects or hands
□Becomes excited when confronted with a variety of visual stimuli	□Wants environment in certain order
□Dislikes having eyes covered	□Other:_____________________________

Touch/Tactile

□Has to know someone is going to touch ahead of time	□Does not like showers or rain on self
□Dislikes being held or cuddled	□Mouths objects or clothing
□Seems irritated when touched or bumped by peers	□Refuses to walk on certain surfaces
□Explores environment by touching objects	□Dislikes having hair, face, or mouth touched
□Dislikes the feel of certain clothing	□Upset by sticky, gooey hands
□Refuses to touch certain things	□Touches items with feet before hands
□Over- or underdresses for the temperature or is unaware of temperature	□Does not like to hold hands
	□Pinches, bites, or hurts her- or himself

Smell/Olfactory

□Sensitive to smells	□Ignores strong odors
□Smells objects, food, people, toys more than usual	□Seeks out certain odors
□Xplores environment by smelling	□Other:____________________________
□Reacts defensively to some smells

Movement/Vestibular

□Seems fearful in space (teeter-totter, climbing)	□Appears clumsy, bumping into things and falling
□Arches back when held or moved	□Avoids balance activities
□Spins or whirls self around	□Does not like to be around people in motion
□Moves parts of body a great deal	□Bumps into things and/or people
□Walks on toes	□Other:____________________________

Visual/Perceptual Motor

□Has trouble with paper/pencil activities	□Has problems with use of some tools
□Has difficulty with time perception	□Has problems organizing materials and moving them appropriately
□Has difficulty with body in space, moving appropriately	□Is distracted by doors and cupboards being open, holes, or motion
	□Other:____________________________

Sensory Supports

Directions: Please put a check next to the item that pertains to your child/student.

Sound/Auditory

□Likes music	□Other: ______________________________
□Likes to sing and/or dance

Taste

□Has definite eating preferences

□Other: ___________________________

Sight/Vision

□Enjoys watching moving things/bright objects	□Likes TV, VCR, videos
□Enjoys patterns or shiny surfaces	□Likes the computer
	□Other: ___________________________

Touch/Tactile

□Likes to be touched	□Prefers certain textures of clothing
□Likes hugs and cuddling when he/she initiates it	□Likes being rolled or sandwiched between blankets/cushions
□Likes to play in water	□Likes rough and tumble play
□Likes baths or swimming pools	□Other: ___________________________
□Seeks out mud, sand, clay to touch
□Prefers deep touching rather than soft

Movement/Vestibular

□Enjoys rocking, swinging, spinning	□Likes to climb, seldom falls
□Likes being tossed in the air	□Other: ___________________________
□Likes to run
□Likes and needs to move

Visual/Perceptual Motor

□Relies on knowing location of furniture, stationary objects	□Other:___________________________
□Likes to draw and reproduce figures

Learning Skills*

Directions: Please answer each item on the scale of 1–4 as it presently applies to your child/student’s level of independence, with “1” meaning “not at all” and “4” meaning “very much.”

		Not at all			Very much
1.	Child clearly understands the end goal of an activity, recognizes what he/she must do to be finished, and persists on the task to completion	1	2	3	4
2.	Child realizes when he/she is running into difficulty and has some way of letting the adult know he/she needs help	1	2	3	4
3.	Once an activity is under way, the adult can walk away from the child and he/she will keep working until finished, maintaining at least fairly good attention to what he/she is doing	1	2	3	4
4.	Child finishes work and remembers on his/her own to let the adult know (e.g., by bringing work to adult, calling adult, raising his/her hand)	1	2	3	4
5.	Child looks forward to earning a reward, knows it’s next, works toward it, may ask for it or go get it on his/her own when work is finished	1	2	3	4
6.	Child is able to wait briefly for a direction (anticipates that he/she is about to be asked to do something), is able to wait briefly for his/her turn with a toy (anticipating that it’s about to return him/her), and / or wait for something to happen	1	2	3	4
7.	Child may be distracted by outside sights and sounds or inner distractions (evident perhaps in singing to him/herself, gazing off, lining up materials) but is able to refocus attention to work on his/her own after a short time and without a prompt or reminder from the adult	1	2	3	4
8.	When one activity is finished, child will look for another to complete	1	2	3	4
9.	Child can organize his/her responses to perform tasks when multiple materials are in front of him/her (e.g., a stack of cards for sorting)	1	2	3	4
10.	Child recognizes when one strategy is not working and tries another way	1	2	3	4
11.	Child recognizes his/her own mistakes and goes back and corrects them (e.g., takes little peg out of big hole to make room for correct peg)

*From TRIAD, adapted from Division TEACCH

Environmental Challenges

Describe environmental challenges of the child/student. Environmental challenges are factors that interfere with the child’s learning. Examples are loud or confusing environments, lack of communication system or lack of sociable peers.

□Behavioral/Knowledge/Attitude of Other People Variables (such as inability to communicate clearly to the student, teach skills necessary for the activity, establish positive work or play routines).

□Procedural/Organizational (such as noisy environments, lack of visual supports, lack of effective transition routines).

□Temporal (such as lack or ineffective use of visual supports to understand passage of time or when activity is finished).

□Spatial (such as lack of personal space or clear boundaries).

Environmental Supports

Describe environmental supports of the child/student. Environmental supports are factors that facilitate learning. Examples are positive routines, use of rewards, and use of visuals supports.

□Behavioral/Knowledge/Attitude of Other People Variables (such as is able to communicate clearly to the student, teach skills necessary for the activity, establish positive work or play routines).

□Procedural/Organizational (such as uncluttered environments, visual supports for understanding work routines, positive transition routines).

□Temporal (such as visual supports to understand passage of time or when activity is finished).

□Spatial (such as personal space to work and calm down, clear boundaries).

Summary of Concerns

Directions: Please list one or two concerns under each area that you have about your child/student as they pertain to succeeding at home and school and being a competent person.

Social and Play Skills

1.

2.

Communication Skills

1.

2.

Learning Skills

1.

2.

Adaptive Skills

1.

2.

List any others on the back of this page.

Appendix C Instructions for Completing COMPASS Challenges and Supports Joint Summary Form

In this section, we provide the COMPASS Challenges and Supports JSF. Using this form, you will summarize the information provided by the COMPASS Challenges and Supports Form for Caregivers and Teachers. The summary that you will compose will ensure that all participants have a common understanding of the child’s personal and environmental challenges as well as the child’s personal and environmental strengths. The COMPASS Challenges and Supports JSF will allow integration of data into an easy-to-read summary. This summary is used to guide the discussion during the COMPASS consultation. Before collating the data, be sure to obtain completed COMPASS Challenges and Supports Form for Caregivers and Teachers from both the caregiver and teacher.

Below are instructions on how to complete the COMPASS Challenges and Supports JSF.

• 1. Enter information on page 1 of the JSF. This includes student’s name, date of birth, and date of consultation. Enter your name, the caregiver’s name, special education teacher’s name, and school name on the respective lines. Then summarize the child’s personal information in the “Student’s Likes, Strengths, Frustrations and Fears” section on the form (pp. 1–2 of the form). List items that both the caregiver and teacher find the student to like or be interested in. Also provide information on the child’s strengths, frustrations, and fears.

• 2. Identify skills that are challenging for the student by using data that the teacher and caregiver provide on the “Adaptive Skills” section. Ratings of 3 and 4 on this form indicate difficult skills. Any time a caregiver or teacher rates a skill with a 3 or 4, place an “X” in the corresponding column.

• 3. The next section, “Problem Behaviors,” utilizes the Problem Behavior Rating Scale. If a caregiver or teacher has marked any of these behaviors with a 3 or 4, place an “X” beside the behavior in the JSF.

• 4. In the “Social / Play Skills” section, place an “S”—indicating strength—in the corresponding box on the form for answers of 3 and 4. Place a “W”—indicating weakness—in the corresponding box on the form for answers of 1 and 2. Note: Be careful to place the “S” or “W” in appropriate box; placing an “S” or “W” in the incorrect box is easy to do and will result in an inaccurate depiction of the student’s social abilities.

• 5. In the “Communication Skills” section, either write or type the examples provided by the caregiver and teacher. Another option is to photocopy the corresponding section of the COMPASS Challenges and Supports Form for Caregivers and Teachers and attach the copies to the JSF.

• 6. In the “Sensory Challenges” section, place a check mark in the corresponding box. Only items that are challenging are of interest in this section.

• 7. Summarize the student’s “Sensory Supports.” Place a check mark in the corresponding box that are supports or motivators for the student. Only items that are strengths or interests are of relevance in this section.

• 8. In the “Learning Skills” section, place an “S”—indicating strength—in the corresponding box on the form for answers of 3 and 4. Place a “W”—indicating weakness—in the corresponding box on the form for answers of 1 and 2. Note: Be careful to place the “S” or “W” in appropriate box; placing an “S” or “W” in the incorrect box is easy to do and will result in an inaccurate depiction of the student’s social abilities.

• 9. The “Environmental Challenges” section can be used to make note of problems that are indicated on the forms or during the consultation.

• 10. The “Environmental Supports” section can be used to note any supports described in the forms or during consultation.

• 11. Finally, in the “Summary of Concerns” list the three concerns for each area as indicated by the caregiver and the teacher.

Appendix D COMPASS Challenges and Supports Joint Summary Form

Child’s/Student’s Name: _______________________ Date of Birth: ___________

Given by:

_________________________________ _______________________________

Consultant Special Ed. Teacher

_________________________________ _______________________________

Caregiver School

Date of Consultation:_____________

Student’s Likes, Strengths, Frustrations and Fears

Likes/Preferences/Interests:

Strengths or Abilities:

Frustrations:

Fears:

Personal Management/Adaptive Skills

These skills were marked as very difficult.

Self-management	Caregiver	Teacher
Performing basic self-care independently (such as toileting, dressing, eating, using utensils)
Entertaining self in free time
Changing activities—transitioning
Sleeping
Responding to Others	Caregiver	Teacher
Following 1 or 2 step direction
Accepting “no”
Answering questions
Accepting help
Accepting correction
Being quiet when required
Understanding Group Behaviors	Caregiver	Teacher
Coming when called to group
Staying within certain places—lines, circles, chairs, desks
Participating with the group
Talking one at a time
Picking up, cleaning up, straightening up, putting away
Understanding Community Expectations	Caregiver	Teacher
Understanding who is a stranger
Going to places in the community (place of worship, stores, restaurants, malls, homes)
Understanding safety (such as streets, seat belts)
Managing transportation (Cars/buses)

Problem Behaviors*

These behaviors were marked as problematic		Teacher	Caregiver
1.	Acting impulsively, without thinking
2.	Hitting or hurting others
3.	Damaging or breaking things that belong to others
4.	Screaming or yelling
5.	Having sudden mood changes
6.	Having temper tantrums
7.	Having a low frustration tolerance; becoming easily angered or upset
8.	Crying easily
9.	Being overly quiet, shy, or withdrawn
10.	Acting sulky or sad
11.	Being underactive or lacking in energy
12.	Engaging in behaviors that may be distasteful to others, such as nose-picking or spitting
13.	Touching him/herself inappropriately
14.	Engaging in compulsive behaviors; repeating certain acts over and over
15.	Hitting or hurting him/herself
16.	Becoming overly upset when others touch or move his/her belongings
17.	Laughing/giggling at inappropriate times
18	Ignoring or walking away from others during interactions or play
19.	Touching others inappropriately
20.	Engaging in unusual mannerisms such as hand-flapping or spinning
21.	Having to play or do things in the same exact way each time
22	Having difficulty calming him/herself down when upset or excited
23.	Other: ______________________________________

*Items are based on the Triad Social Skills Assessment

Social and Play Skills

How well does the child/student		With adults		With children
Social Awareness		Teacher	Caregiver	Teacher	Caregiver
1.	Look toward a person who is talking to him/her
2.	Accept others being close to him/her
3.	Watch people for extended periods of time
4.	Respond to another person’s approach by smiling or vocalizing
5.	Initiate interactions for social reasons
Joint Attention Skills
6.	Look at something another person points to
7.	Show something to a person and look for person’s reaction
8.	Point at an object or event to direct another person’s attention to share enjoyment
9.	Share smile by looking back and forth between object and person
Imitation
10.	Imitate sounds another person makes
11.	Imitate what another person does with an object (e.g., person makes toy airplane fly, child repeats action)
12.	Imitate body movements of others (such as clap when others clap, play Simon Says)
13.	Imitate and expand upon other’s actions with toys (e.g., peer beats drum, child beats drum and also starts to march)
Play
14.	Take turns within familiar routines (e.g., rolls a ballback and forth)
15.	Share toys
16.	Play interactively around a common theme
17.	Repair breakdowns during interactions (such as the child repeats or changes own behavior when other person seems confused or ignores)
18.	Pretends to do something or be something (such as that a plate is a hat by putting it on, to be a policeman, to have a tea party, that a doll is a teacher)

Communication Skills

The following are descriptions of words or actions your child/student uses to communicate:

Making Requests	Teacher	Caregiver
1. Food
2. Objects
3. An activity
4. To use the toilet
5. Attention
6. Help
7. To play
8. Information
9. A choice
Expressing Refusals	Teacher	Caregiver
1. “Go away”
2. “No, I won’t do it” or “I don’t want it”
3. “I want to be finished” or “I want to stop doing this”
Expressing Thoughts	Teacher	Caregiver
1. Greeting to others
2. Comments about people/environment
3. Confusion or “I don’t know”
4. Comments about errors or things wrong
5. Asks about past or future events
6. Agreement
Expressing Feelings	Teacher	Caregiver
1. Angry/mad/frustrated
2. Pain/illness/hurt
3. Happy/excited
4. Hurt feelings/upset
5. Afraid
6. Sad

Sensory Challenges

These items were identified as being applicable to your child/student:

Sound/Auditory	Teacher	Caregiver
Has been diagnosed with hearing problem at some time	□	□
Reacts to unexpected sounds	□	□
Fears some noises	□	□
Distracted by certain sounds	□	□
Confused about direction of sounds	□	□
Makes self-induced noises	□	□
Fails to listen or pay attention to what is said to him/her	□	□
Talks a great deal	□	□
Own talking interferes with listening	□	□
Overly sensitive to some sounds	□	□
Seeks out certain noises or sounds	□	□
Other:__________________________________________________	□	□
Taste	Teacher	Caregiver
Has an eating problem	□	□
Dislikes certain foods and textures	□	□
Will only eat a small variety of foods	□	□
Tastes/eats nonedibles	□	□
Explores environment by tasting	□	□
Puts most things in his/her mouth	□	□
Constant chewing on something	□	□
Other:__________________________________________________	□	□
Sight/Vision	Teacher	Caregiver
Has trouble discriminating shapes, colors	□	□
Is sensitive to light—squints, wants to wear hats or sunglasses	□	□
Has trouble following with eyes	□	□
Does not make much eye contact	□	□
Is distracted by some or too much visual stimuli	□	□
Becomes excited when confronted with a variety of visual stimuli	□	□
Dislikes having eyes covered	□	□
Excited by vistas and open spaces	□	□
Hesitates going up or down stairs, curbs, or climbing equipment	□	□
Upset by things looking different (spills, spots)	□	□
Makes decisions about food, clothing, objects by sight	□	□
Closely examines objects or hands	□	□
Wants environment in certain order	□	□
Other:__________________________________________________	□	□
Touch/Tactile	Teacher	Caregiver
Has to know someone is going to touch ahead of time	□	□
Dislikes being held or cuddled	□	□
Seems irritated when touched or bumped by peers	□	□
Explores environment by touching objects	□	□
Dislikes the feel of certain clothing	□	□
Refuses to touch certain things	□	□
Over or under dresses for the temperature or is unaware of temperature	□	□
Does not like showers or rain on self	□	□
Mouths objects or clothing	□	□
Refuses to walk on certain surfaces	□	□
Dislikes having hair, face, or mouth touched	□	□
Upset by sticky, gooey hands	□	□
Touches items with feet before hands	□	□
Does not like to hold hands	□	□
Pinches, bites, or hurts himself	□	□
Other:__________________________________________________	□	□
Smell/Olfactory	Teacher	Caregiver
Sensitive to smells	□	□
Smells objects, food, people, toys more than usual	□	□
Explores environment by smelling	□	□
Reacts defensively to some smells	□	□
Ignores strong odors	□	□
Seeks out certain odors	□	□
Other:__________________________________________________	□	□
Movement/Vestibular	Teacher	Caregiver
Seems fearful in space (teeter-totter, climbing)	□	□
Arches back when held or moved	□	□
Spins or whirls self around	□	□
Moves parts of body a great deal	□	□
Walks on toes	□	□
Appears clumsy, bumping into things and falling down	□	□
Avoids balance activities	□	□
Does not like to be around people in motion	□	□
Bumps into things and/or people	□	□
Other:__________________________________________________	□	□
Visual/Perceptual Motor	Teacher	Caregiver
Has trouble with paper/pencil activities	□	□
Has difficulty with time perception	□	□
Has difficulty with body in space—moving appropriately	□	□
Has problems with use of some tools	□	□
Has problems organizing materials and moving them appropriately	□	□
Is distracted by doors and cupboards being open, holes, or motion	□	□
Other:__________________________________________________	□	□

Sensory Supports

These items were identified as being applicable to your child/student:

Sound/Auditory	Teacher	Caregiver
Likes music	□	□
Likes to sing and dance	□	□
Taste
Has definite eating preferences	□	□
Other:__________________________________________________	□	□
Sight/Vision	Teacher	Caregiver
Enjoys watching moving things/bright objects	□	□
Enjoys patterns or shiny surfaces	□	□
Likes TV, videos, video games	□	□
Likes the computer	□	□
Other:__________________________________________________	□	□
Touch/Tactile	Teacher	Caregiver
Likes to be touched	□	□
Likes hugs and cuddling when he/she initiates it	□	□
Likes to play in water	□	□
Likes baths or swimming pools	□	□
Seeks out mud, sand, clay to touch	□	□
Prefers deep touching rather than soft	□	□
Prefers certain textures of clothing	□	□
Likes being rolled or sandwiched between blankets/cushions	□	□
Likes rough and tumble play	□	□
Other:__________________________________________________	□	□
Movement/Vestibular	Teacher	Caregiver
Enjoys rocking, swinging, spinning	□	□
Likes being tossed in the air	□	□
Likes to run	□	□
Likes and needs to move	□	□
Likes to climb; seldom falls	□	□
Other:__________________________________________________	□	□
Visual/Perceptual Motor	Teacher	Caregiver
Relies on knowing location of furniture, stationary objects	□	□
Likes to draw and reproduce figures	□	□
Other:__________________________________________________	□	□

Learning Skills

Learning/Work Skill		Caregiver	Teacher
1.	Child clearly understands the end goal of an activity, recognizes what he/she must do to be finished, and persists on the task to completion
2.	Child realizes when he/she is running into difficulty and has some way of letting the adult know he/she needs help
3.	Once an activity is under way, the adult can walk away from the child and he/she will keep working until finished, maintaining at least fairly good attention to what he/she is doing
4.	Child finishes work and remembers on his/her own to let the adult know (e.g., by bringing work to adult, calling adult, raising his/her hand)
5.	Child looks forward to earning a reward, knows it’s next, work toward it, may ask for it or go get it on his/her own when work is finished
6.	Child is able to wait briefly for a direction (anticipates that he/she is about to be asked to do something), is able to wait briefly for his/her turn with a toy (anticipating that it’s about to return him/her), and / or wait for something to happen
7.	Child may be distracted by outside sights and sounds or inner distractions (evident perhaps in singing to him/herself, gazing off, lining up materials) but is able to refocus attention to work on his/her own after a short time and without a prompt or reminder from the adult
8.	Child shows interest in and curiosity about materials, handles them without prompting or nudging from the adult to get started. When one activity is finished he/she will look for another
9.	Child can organize his/her responses to perform tasks when multiple materials are in front of him/her (e.g., a stack of cards for sorting)
10.	Child recognizes when one strategy is not working and tries another way
11.	Child recognizes his/her own mistakes and goes back and corrects them (e.g., takes little peg out of big hole to make room for correct peg)

Environmental Challenges

Describe challenges noted in the Forms or reported during the consultation:

□Behavioral/Knowledge/Attitude of Other People Variables (such as inability to communicate clearly to the student, teach skills necessary for the activity, establish positive work or play routines).

□Procedural/Organizational (such as noisy environments, lack of visual supports, lack of effective transition routines).

□Temporal (such as lack or ineffective use of visual supports to understand passage of time or when activity is finished).

□Spatial (such as lack of personal space or clear boundaries).

Environmental Supports

Describe supports noted in the Forms or reported during the consultation:

□Behavioral/Knowledge/Attitude of Other People Variables (such as is able to communicate clearly to the student, teach skills necessary for the activity, establish positive work or play routines).

□Procedural/Organizational (such as uncluttered environments, visual supports for understanding work routines, positive transition routines).

□Temporal (such as visual supports to understand passage of time or when activity is finished).

□Spatial (such as personal space to work and calm down, clear boundaries).

Summary of Concerns

Social and Play Skills

Teacher	Caregiver
1.	1.
2.	2.

Communication Skills

Teacher	Caregiver
1.	1.
2.	2.

Learning Skills

Teacher	Caregiver
1.	1.
2.	2.

Adaptive Skills

Teacher	Caregiver
1.	1.
2.	2.