Profile Questionnaire: for Caregivers and Professionals, Tele-Collaboration in Speech and Hearing Sciences: Social Communication

Profile Questionnaire:
for Caregivers and Professionals

Social Communication Model
Behaviors | Cognitive | Language | Processing

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Are you a Caregiver or Professional?
In which country do you currently reside?

If a professional: Are you a Teacher Teacher’s Assistant Speech-Language Pathologist Physical Therapist Occupational Therapist School Psychologist Other
Current work setting: schools hospital/medical setting private practice university other clinical setting unemployed
Years as a Professional: 1-5 6-10 11-15 16-20 21+
Comfort Level in assessing social communication problems in school age children: very comfortable somewhat comfortable not comfortable
Comfort Level in treating social communication problems in school age children: very comfortable somewhat comfortable not comfortable
Educational preparation for working on social communication problems: very well-prepared somewhat prepared not prepared

If you are a caregiver: You are the child's Adoptive Parent Biological Parent Foster Parent Grandparent Other
Do you have other children? yes no If yes, how many?
Do any of your other children exhibit social communication problems? yes no

Information about child for whom you are profiling: Child is a boy or girl
Child is years and months old
Child is in a	regular classroom--no support services regular classroom--with support services special education classroom
Do support services include speech and language? Yes No Not Applicable
Child has been diagnosed has having (check all that apply): Specific Language Impairments/Language Learning Disabilities Attention Deficit/Hyperactivity Disorders Autism Spectrum Disorders/Pervasive Developmental Disabilities Fetal Alcohol Syndrome/Alcohol Related Disabilities Obsessive Compulsive Disorders Nonverbal Learning Disabilities Other:

Which social communication problems does your child demonstrate?	Yes, based on information from:			No	Don’t Know
	Standardized Tests	Behavioral Observation or Nonstandardized Measures	Caregiver or Teacher Report	No	Don’t Know
Difficulty entering a peer group.
Difficulty collaborating.
Difficulty offering help.
Difficulty asking permission.
Difficulty waiting turn.
Difficulty telling the truth.
Difficulty explaining behaviors.
Difficulty negotiating conflict with peers.
Difficulty making and keeping friends.

Which social communication problem occurs most frequently?	Entering a Peer Group Collaborating Offering Help Explaining Behaviors Asking Permission	Waiting Turn Telling the Truth Negotiating Peer Conflict Making and Keeping Friends
In which school settings do these social communication problems primarily occur? (check all that apply)	Classroom free time Classroom cooperative activity Classroom study time Classroom silent reading Classroom discussion Computer time	Recess Lunch Assembly P.E./Gym Transition between periods I don't know
Which school setting is the primary location where social communication problems occur?	Classroom free time Classroom cooperative activity Classroom study time Classroom silent reading Classroom discussion Computer time	Recess Lunch Assembly PE/Gym Transition between periods I don't know
When your child interacts with peers, what does his/her behavior look like? (check all that apply)	Socially Appropriate and Polite Hostile/Coercive Assertive	Passive Adult Seeking Irrelevant

Have you observed your child exhibiting any of the following social cognitive deficits?	Yes, based on information from:			No	Don’t Know
	Standardized Tests	Behavioral Observation or Nonstandardized Measures	Caregiver or Teacher Report	No	Don’t Know
Encode/Interpret Cues
Difficulty interpreting social cues.
Difficulty speculating why an event occurred.
Difficulty knowing what to do next in social situations.
Difficulty appreciating beliefs, ideas and knowledge of others.
Decreased attention for environment in general.
Difficulty attending to relevant cues.
Decreased awareness of peer activities.
Inappropriate focus on self-chosen activity.
Clarification of Goals
Difficulty formulating and pursuing goals involving others (e.g., being first in line at the water fountain).
Difficulty formulating and pursuing internal state goals (e.g., feeling happy; avoiding embarrassment).
Response Strategies
Difficulty selecting effective responses/strategies for:
a. Entering a group.
b. Resolving conflicts.
c. Maintaining play.
Difficulty using alternative responses/strategies in solving dilemmas.
Difficulty understanding consequences of decisions.
Not having necessary behaviors to perform competently.

Have you observed your child exhibiting any of the following language deficits?	Yes, based on information from:			No	Don’t Know
	Standardized Tests	Behavioral Observations or Nonstandardized Measures	Caregiver or Teacher Report	No	Don’t Know
Lack of variety in vocabulary.
Limited production of mental state verbs (think, know, believe, wonder).
Limited production of emotion words (like, hate, confused).
Limited production of complex syntactic forms (relative clause).
Limited production of temporal and/or causal conjunctions (although, because).
Difficulty in providing clear referents for pronouns .
Difficulty stating topics.
Difficulty maintaining topics.
Difficulty asking the right questions for needed information.
Difficulty providing significant and sufficient information.
Difficulty being polite.
Difficulty taking turns.

Have you observed your child exhibiting any of the following processing deficits?	Yes, based on information from:			No	Don’t Know
	Standardized Tests	Behavioral Observation or Nonstandardized Measures	Caregiver or Teacher Report	No	Don’t Know
Difficulty planning for future activities, tasks or situations.
Difficulty inhibiting competing or irrelevant responses.
Difficulty analyzing situations before acting.
Difficulty staying engaged with a task for appropriate length of time.
Difficulty altering approach when confronted with failure.
Difficulty adjusting to different styles of interaction and instruction.
Difficulty managing task-induced anxiety.
Difficulty holding own ground when arguing a point of view.
Difficulty using self-talk, or speech of another person, to control behavior.
Difficulty managing and directing social interactions.
Difficulty solving problems by coordinating or adapting several pieces of information.

University of Washington, Dept. of Speech & Hearing Sciences, Tele-Collaboration Project.
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