Caregiver Assessment Form

SECTION A – Client Identification

SECTION B – Rating Scale Key

For each question below, select ONE number that best describes your experience:

SECTION C – Behaviour & Safety

Q3. How often does your child display aggressive behaviour, hurt themselves, run away, or cause disruptions that affect their safety or daily functioning?

Consider incidents at home, school, or in public.

SECTION D – Communication & Expression

Q4. How often does your child struggle to express their needs or wants, leading to frustration or behavioural outbursts?

Think about how your child communicates when upset or in need.

SECTION E – Caregiver Wellbeing

Q5. How often do you feel overwhelmed as a caregiver, to the point that it affects your ability to apply consistent behavioural strategies with your child?

Be honest — this helps us understand your own support needs.

SECTION F – Household Economic Capacity

Q6. What best describes the current employment situation in your household?

Select the one option that most accurately reflects your situation.

SECTION G – Social & Community Support

Q7. How often do you feel that you have little or no help from family members or your community in managing your child's behavioural needs?

Consider support from extended family, neighbours, faith communities, or other networks.

SECTION H – Diagnosis & Co-occurring Conditions

Q8. To what extent do your child's diagnosed condition(s) such as autism, ADHD, anxiety, or others require integrated and intensive behavioural support beyond standard therapy?

Think about how much the diagnosis affects daily life and coordination of care.

SECTION I – Access to Therapy

Q9. How much does distance from our facility, transportation challenges, or scheduling difficulties affect your ability to attend therapy sessions regularly?

Rate 1 (No barrier) to 5 (Severe barrier — almost impossible).