Autism Spectrum Disorder (ASD) Adult Intake Form
Personal Information
Full Name
Date of Birth
Age
Gender
Address
Phone
Email
Emergency Contact (Name & Relationship)
Emergency Contact Phone
Referral Information
How did you hear about us?
Reason for referral / main concerns
Developmental & Medical History
Current and past diagnoses (including mental health, medical, neurological)
Current medications and dosages
Significant medical or health problems
Family history of ASD or other developmental/mental health conditions
Education & Employment
Educational background
Current employment or vocation
Social & Daily Functioning
Current living situation (alone, with family, etc.)
Significant relationships and social connections
Any challenges with daily living skills (self-care, cooking, etc.)
Other Relevant Information
Interests, strengths, or skills
Goals and expectations from this assessment or service