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Autism Client Evaluation Forms
April 30 2009

The Autism Symptom Elimination Study
The Subcellular Cause of Autism
Long-Term Autism Treatment Results
Autism Client Evaluation Forms
Trauma-based Approaches by Other Researchers
For treatment of Asperger's Syndrome,
click here.

Procedural steps for the autistic client:

Before the procedure:

  1. Determine if the client can use EFT successfully.
  2. Make sure the Liability and Confidentiality form is filled out by the guardian or client.
  3. Use the standard form attached to evaluate the degree of autism in the client BEFORE the procedure. Please fill out the form on-line at, and be sure to include the Institute email address given to you so that we receive it. (The form is shown below for your information.)
  4. We have different ways we work with clients. The most typical is with the initial treatment being done with a facilitator physically present, and with an ISPS research member on the phone. In some cases, the therapists work via skype on the client without being physically present.
  5. Be sure you understand that the process is experimental: there may be unexpected side effects, requiring interventions over the next few days; and the possibility exists that there may be other problems arise that we don't yet know how to treat.

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 treatment session. For research sessions, we may have over a dozen sessions; for the typical client, only two or three.
  3. Although it is unlikely, be prepared for strong abreactions after the treatment.

Requirements after the process:
  1. Have the guardian fill out the standard evaluation form AGAIN a week after the process is run (or if the treatment is over a period of time, when we ask for another evaluation.)
  2. Plan on at least three follow up healing session after the last treatment 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 to discuss the results of treatment with interested people and organizations.

Autism Treatment Evaluation Checklist (ATEC)

The following questions are from the Autism Research Institute's ATEC form. Please fill out the form online, and be sure to enter the Institute email address at the bottom of the form so it will be sent to us. You can find the questionnaire at

If you are interested in finding out more about this questionnaire, please check the Autism Research Institute website 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


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:



Last Name / First Name of Child [or identification code]:

Sex of Child: Male Female
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]


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

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

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

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
3310 Cowie Road, Hornby Island, BC
V0R 1Z0

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Revision History
Dec 13, 2013: Updated the ATEC online form link.
April 30, 2009: Changed the autism evaluation form to being filled out online, and rewrote steps for more research and development involvement.
November 2006: Added the Autism Research Institute evaluation form for testing autism changes.