100 DAY KIT FOR SCHOOL AGE CHILDREN

Comparing Treatment Methods & Providers

Adapted from: Does My Child Have Autism? By Wendy L. Stone, Ph.D. with Theresa Foy DiGeronimo  

ABOUT THE PROGRAM

Name of Program/Provider
Method
Location
Phone Number
Email
Website
Hours per Week
Cost
Reimbursement
Recommended by

PROGRAM CONTENT
What are the developmental areas
of focus? (language, communication,
peer play, social interactions, behavior,
pre-academic skills, parent training,
etc.)
How specific are the goals
identified for each child?

How are behaviors and skills

prioritized?

What kind of teaching is used?

How are behaviors managed?

MEASURING PROGRESS
How will I know if my child is
making progress?

How long will it be before I see

changes?

What types of improvements

should I expect?

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How often will you assess progress

and how is it measured?

What will happen if my child

doesn’t make progress with this
treatment?

THERAPIST QUALIFICATIONS
How many children with autism
have you worked with? What
ages?

Do you serve children over three

years old?

What are your qualifications? What

type of training do you have?

Do you have a professional degree

or certificate? (Ask for details.)

Are you affiliated with a

professional organization? (Ask for
details.)

What do you see as your strongest

skill in working with children with
autism?

Are there issues or problems you

consider to be outside of your
realm of expertise?

SCIENTIFIC EVIDENCE OF EFFECTIVENESS

Is there research to support the
effectiveness of this type of
treatment? (Ask for details as well
as copies of published articles.)

Has research shown this treatment

to be better than other types of
treatment?

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PROFESSIONAL INVOLVEMENT
Who will be providing the direct
intervention with my child?

What type of training does he/she

have?

Who will be supervising him/her

and how?

How often will you see my child

personally?

PARENT INVOLVEMENT
Will I be able to participate in the
treatment?

Will you teach me how to work with

my child? How?

What skills will you teach me? (Ask

for examples.)

COMPATIBILITY WITH OTHER TREATMENTS

How many hours per week of your
treatment will my child need?

Is your treatment compatible with

other interventions my child is
participating in?

How do you collaborate with other

therapy providers on my child’s
team? (Get examples.)

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 Service Provider Planner
Requested #
Agency & Requested
Phone # Date Called of Sessions Availability Status Follow-Up Other Info
Contact Services and Duration

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 Service Provider Planner
Requested #
Agency & Phone # Date Called Requested of Sessions Availability Status Follow-Up Other Info
Contact Services and Duration

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CONTACTS: MEDICAL
Specialty Specialty

Name of Name of
Contact Contact
Name of Name of
Practice Practice
Phone Number Phone Number

Address Address

Email Address/ Email Address/

Website Website

Specialty Specialty

Name of Name of
Contact Contact
Name of Name of
Practice Practice
Phone Number Phone Number

Address Address

Email Address/ Email Address/

Website Website

Specialty Specialty

Name of Name of
Contact Contact
Name of Name of
Practice Practice
Phone Number Phone Number

Address Address

Email Address/ Email Address/

Website Website

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CONTACTS: THERAPY
Specialty Specialty

Name of Name of
Contact Contact
Name of Name of
Practice Practice
Phone Number Phone Number

Address Address

Email Address/ Email Address/

Website Website

Specialty Specialty

Name of Name of
Contact Contact
Name of Name of
Practice Practice
Phone Number Phone Number

Address Address

Email Address/ Email Address/

Website Website

Specialty Specialty

Name of Name of
Contact Contact
Name of Name of
Practice Practice
Phone Number Phone Number

Address Address

Email Address/ Email Address/

Website Website

 
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CONTACTS: SUPPORT
Specialty Specialty

Name of Name of
Contact Contact
Name of Name of
Practice Practice
Phone Number Phone Number

Address Address

Email Address/ Email Address/

Website Website

Specialty Specialty

Name of Name of
Contact Contact
Name of Name of
Practice Practice
Phone Number Phone Number

Address Address

Email Address/ Email Address/

Website Website

Specialty Specialty

Name of Name of
Contact Contact
Name of Name of
Practice Practice
Phone Number Phone Number

Address Address

Email Address/ Email Address/

Website Website

 
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CONTACTS: OTHER
Specialty Specialty

Name of Name of
Contact Contact
Name of Name of
Practice Practice
Phone Number Phone Number

Address Address

Email Address/ Email Address/

Website Website

Specialty Specialty

Name of Name of
Contact Contact
Name of Name of
Practice Practice
Phone Number Phone Number

Address Address

Email Address/ Email Address/

Website Website

Specialty Specialty

Name of Name of
Contact Contact
Name of Name of
Practice Practice
Phone Number Phone Number

Address Address

Email Address/ Email Address/

Website Website

 
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PHONE LOG
NAME OF CONTACT: _________________________________

PHONE NUMBER: ___________________________________

Date/Time
Summary of Call

Follow-up
Required

Date/Time
Summary of Call

Follow-up
Required

Date/Time
Summary of Call

Follow-up
Required

Date/Time
Summary of Call

Follow-up
Required

Date/Time
Summary of Call

Follow-up
Required

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PHONE LOG
NAME OF CONTACT: _________________________________

PHONE NUMBER: ___________________________________

Date/Time
Summary of Call

Follow-up
Required

Date/Time
Summary of Call

Follow-up
Required

Date/Time
Summary of Call

Follow-up
Required

Date/Time
Summary of Call

Follow-up
Required

Date/Time
Summary of Call

Follow-up
Required

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PHONE LOG
NAME OF CONTACT: _________________________________

PHONE NUMBER: ___________________________________

Date/Time
Summary of Call

Follow-up
Required

Date/Time
Summary of Call

Follow-up
Required

Date/Time
Summary of Call

Follow-up
Required

Date/Time
Summary of Call

Follow-up
Required

Date/Time
Summary of Call

Follow-up
Required

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 ASSESSMENT TRACKING Type of Therapy _______________
Test Change in Change in Age
Date Evaluator Standard Score Age Equivalent
Administered Standard Score Equivalent

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100 DAY KIT FOR SCHOOL AGE CHILDREN
 ASSESSMENT TRACKING Type of Therapy _______________
Test Change in Change in Age
Date Evaluator Standard Score Age Equivalent
Administered Standard Score Equivalent

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 100 DAY KIT FOR SCHOOL AGE CHILDREN

Sample Bullying Response Letter

Your street address
City, state zip code

Date

Name of Principal
Name of School
School street address
City, state zip code

RE: First and last name of child

Dear (name of Principal),

My child, first name of child is in the (grade level) at (name of school). At school (s/he) has been bullied
and harassed by (name of harasser(s)). This has occurred on (date or approximate period of time) when
(describe as many details of the incident(s) as can be recalled). When this happened, (name of wit-
ness(es)) heard or saw it and (their response(s)). We became aware of this incident when (describe how
you were notified).

(First name of child) was hurt by this bullying and harassment. (S/He) had (describe physical injuries,
emotional suffering and any medical or psychological treatment required). As you are likely aware, (first
name of child) has an IEP (Individual Education Plan).

(I/we) became aware of three federal laws (Section 504 of the Rehabilitation Act of 1973, Title II of the
Americans with Disabilities Amendment Act (ADAAA) of 2008, and Individuals with Disabilities Education
Act (IDEA)) that protect the rights of a child with a disability against bullying behavior that is based on the
child’s disabilities and that interferes with or denies the child the opportunity to participate in or benefit
from an educational program.

Please send (me/us) a copy of the District policies on bullying and harassment, investigate this problem
and correct it as soon as possible. Please let (me/us) know, in writing, of the actions you have taken to
rectify the situation and to ensure it does not happen again. If this does not resolve this issue, (I/we) will
request an IEP meeting to be held as quickly as possible. I expect a response within 5 business days.

Thank you for your prompt attention to this serious problem.

Sincerely,
(sign in this area)
Your Name

CC: Name of Director of Special Education

Name of Superintendent of Schools

From PACER’s National Bullying Prevention Center ®, Minneapolis, MN. PACER.org

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Sample Request for Special Education Eligibility Evaluation

Date:
To:
Re: (Child’s name), Request for Evaluation

Dear (Director of Special Education),

My name is (name) and I am writing to you because my child, (child’s name), is having some trou-
bles in school. I believe that special education programs could help with (his/her) difficulties.
I am formally requesting that the school immediately begin process for instituting a special education
program. I understand that this process begins with the initial evaluation to determine eligibility and
that you will send me an evaluation plan that explains the tests you will administer to (child’s name).
If possible, I would like to receive the plan within 10 days so that I have time to prepare for the pro-
cess. Once I have given my consent for the plan, please let me know the date you set for the eval-
uation. I would greatly appreciate any other information you have regarding the evaluation process,
including your criteria for determining eligibility and general IEP framework.

Thank you for your time and your help in this matter. I look forward to working with the school to
make sure (child’s name) gets the education (he/she) needs.

Sincerely,

(Your signature)

(Your name)

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GOAL TRACKING: IEP

IFSPGOALS
GOALS
Goals
Date Comments Goals Making Goals Just Goals Not
Mastered Progress Started Started

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 Safety Log
In the chart below, include any wandering incidents, attempts or interactions that put your child at risk. Keep track of what
was going on before, during and after the incident to try and determine antecedents, triggers and possible prevention
methods. Ask your child’s behavioral team, teachers and other caregivers to complete the log as needed.

Date Location Description Possible Triggers Changes Noted Suggested Next Steps

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 AutismSafety
From www.AWAARE.org
Autism Elopement Alert Form Part 1
PERSON-SPECIFIC INFORMATION FOR FIRST RESPONDERS

Individual’s Name
(First) (M.I.) (Last ) ATTACH CURRENT
Address PHOTO HERE

(Street) (City) (State) Zip)

Date of Birth Age Preferred Name

Date Submitted:
Does the individual live alone?

Individual’s Physical Description:

Male Female Height: Weight: Eye color: Hair color:
Scars or other identifying marks:
Other Relevant Medical Conditions in addition to Autism (check all that apply):
No Sense of Danger Blind Deaf Non-Verbal Mental Retardation
Prone to Seizures Cognitive Impairment Other

If Other, Please Explain:

Prescription Medications Needed:

Sensory or Dietary Issues, If Any:

Additional Information First Responders May Need:

EMERGENCY CONTACT INFORMATION

Name of Emergency Contact (Parents/Guardians, Head of Household/Residence, or Care Providers):

Emergency Contact’s Address:

(Street) (City) (State) Zip)
Emergency Contact’s Phone Numbers:
Home: Work: Cell Phone:

Name of Alternative Emergency Contact:

Home: Work: Cell Phone:

Part of the Autism Speaks Autism Safety Kit

 AutismSafety Autism Elopement Alert Form
Part 2

INFORMATION SPECIFIC TO THE INDIVIDUAL

Favorite attractions or locations where the individual may be found:

Atypical behaviors or characteristics of the Individual that may attract the attention of Responders:

Individual’s favorite toys, objects, music, discussion topics, likes, or dislikes:

Method of Preferred Communication. (If nonverbal: Sign language, picture boards, written words, etc.):

Method of Preferred Communication II. (If verbal: preferred words, sounds, songs, phrases they may respond to):

Identification Information. (i.e. Does the individual carry or wear jewelry, tags, ID card, medical alert bracelets, etc.?):

Tracking Information. (Does the individual have a Project Lifesaver or LoJack SafetyNet Transmitter Number?):

Part of the Autism Speaks Autism Safety Kit

 AutismSafety Neighbor Alert Letter
Police Officer Laurie Reyes of Montgomery County Police Department has responded to dozens
of autism wandering emergencies, and recommends providing this letter to trusted neighbors
to inform them of your child with autism’s tendency to wander.

Dear Neighbor,

We have a child with autism. About half of children with autism have a tendency to wander from safety.

We watch our child very carefully, but sometimes he/she unpredictably wanders away from safety.

Our child’s name is . He/she is years old as

of today, . He/she is tall and weighs about lbs.
He/she usually wears .

WHAT TO DO?
We kindly ask if you see our child alone, please stay with him/her and immediately call:
. We are probably already looking for him/her. Please also call 911 and
tell them that you have found our child.

Our child, , does not speak very well and does not appreciate danger.
He/she might walk into the street without looking. He/she may be dangerously drawn to bodies of water
like lakes, rivers or swimming pools and could drown. He/she might walk in your house or yard if a door
or gate is open. He/she will become lost very easily and not know he/she is lost. If you ask our child a
question he/she will likely not answer.

Our child may appear to be deaf. However, our child can hear. But he/she may not react to things that he/
she hears or sees or respond to your verbal commands.

Our child sometimes has outbursts where he/she might scream or shake his/her hands, or act in other
unusual ways for a few moments. Please don’t misinterpret any of these motions. He/she does not intend
to hurt anyone. If you see our child please stay with him/her and call us, then 911 right away.

We have included a recent picture of our child.

Thank you,

(Parent Name)
(Address)
(Phone)

To learn more about autism, please visit www.autismspeaks.org.

Part of the Autism Speaks Autism Safety Kit