Double Board Certified Counseling Services

Mark Zauss, LMHC, LPC, CCMHC, NBCC, BC-TMC, ADHD-CCSP, C-DBT, CCTP

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Autism Spectrum–Related Developmental History (Childhood)

Rate how often the statements were true during **childhood (ages 0–12)**. Scale: 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Often, 4 = Very Often. This is an **educational screener** to support case formulation—not a diagnosis.

Instructions & Quick Fill

Complete each item below. Subscale and Total scores auto-calculate. Milestone flags (walk/first words/two-word phrases) are also summarized.

Fill all 0 Fill all 1 Fill all 2 Fill all 3 Fill all 4

Developmental Milestones (Childhood)

Age walked independently (months)

Age first words (months)

Age two-word phrases (months)

Early interventions / services (if any)

Developmental / learning diagnoses (if any)

autism developmental history, childhood social delay, speech delay, face recognition, academic executive challenges, sensory differences, self-scoring screener, Double Board Certified Counseling Services, Mark Zauss

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