Social Communication Questionnaire (SCQ)

Social Communication Questionnaire (SCQ)

Provided by: Wellness Grove
Client Legal Name

First NameMiddle NameLast Name
Client Preferred Name
Client Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Client Last 4 of SS#
Client Email Address

Confirmation Emailexample@example.com
Name of Individual Completing the Client Packet (Adult) (if not the client)

First NameLast Name
Relationship to the client (if not the client)

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By signing this form electronically and clicking on "Sign & Submit", you are certifying that the information given on this form is true and correct to the best of your knowledge. Please note that an e-signature is the electronic equivalent of a hand-written (pen-and-paper) signature.
Client/Representative Legal Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
If Parent/Guardian/Legal Representative, please describe your relationship to the client
Should be Empty:

Rows	Yes	No
2. Do you have a to-and-fro "conversation" with her/him that involves taking turns or building on what you have said?
3. Does she/he ever use odd phrases or say the same thing over and over in almost exactly the same way (either phrases that she/he hears other people use or ones that she/he makes up)?
4. Does she/he ever use socially inappropriate questions or statements? For example, does she/he regularly ask personal questions or make personal comments at awkward times?
5. Does she/he ever get her/his pronouns mixed up (e.g. saying you or she/he for I)?
6. Does she/he ever use words that she/he seems to have invented or made up herself/himself; put things in odd, indirect ways; or use metaphorical ways of saying things (e.g. saying hot rain for steam)?
7. Does she/he ever say the same thing over and over in exactly the same way or insist that you say the same thing over and over again?
8. Does she/he ever have things that she/he seems to have to do in a very particular way or order or rituals that she/he insists that you go through?
9. Does her/his facial expression usually seem appropriate to the particular situation, as far as you can tell?
10. Does she/he ever use your hand like a tool or as if it were part of her/his own body (e.g. pointing with your finger, putting your hand on a doorknob to get you to open the door)?
11. Does she/he ever have any interests that preoccupy her/him and might seem odd to other people (e.g. traffic lights, drainpipes, timetables)?
12. Does she/he ever seem to be more interested in parts of a toy or an object (e.g. spinning the wheels of a car), rather than in using the objects as it was intended?
13. Does she/he ever have any special interests that are unusual in their intensity but otherwise appropriate for her/his age and peer group (e.g. trains or dinosaurs)?
14. Does she/he ever seem to be unusually interested in the sight, feel, sound, taste, or smell of things or people?
15. Does she/he ever have any mannerisms or odd ways of moving her/his hands or fingers, such as flapping or moving her/his fingers in front of her/his eyes?
16. Does she/he ever have any complicated movements of her/his whole body, such as spinning or repeatedly bouncing up and down?
17. Does she/he ever injure herself/himself deliberately, such as biting her/his arm or banging her/his head?
18. Does she/he ever have any objects (other than a soft toy or comfort blanket) that she/he has to carry around?
19. Does she/he ever have any particular friends or a best friend?
20. Does she/he ever talk to you just to be friendly (rather than to get something)?
21. Does she/he ever spontaneously copy you (or other people) or what you are doing (such as vacuuming, gardening, or mending things)?
22. Does she/he ever spontaneously point at things around her/him just to show you things (not because she/he wants them)?
23. Does she/he ever use gestures, other than pointing or pulling your hand, to let you know what she/he wants?
24. Does she/he nod her/his head to indicate yes?
25. Does she/he shake her/his head to indicate no?
26. Does she/he usually look at you directly in the face when doing things with you or talking with you?
27. Does she/he smile back if someone smiles at her/him?
28. Does she/he ever show you things that interest her/him to engage your attention?
29. Does she/he ever offer to share things other than food with you?
30. Does she/he ever seem to want you to join in her/his enjoyment of something?
31. Does she/he ever try to comfort you if you are sad or hurt?
32. If she/he wants something or wants help, does she/he look at you and use gestures with sounds or words to get your attention?
33. Does she/he show a normal range of facial expressions?
34. Does she/he ever spontaneously join in and try to copy the actions in social games, such as The Mulberry Bush or London Bridge Is Falling Down?
35. Does she/he play any pretend or make-believe games?
36. Does she/he seem interested in other children of approximately the same age whom she/he does not know?
37. Does she/he respond positively when another child approaches her/him?
38. If you come into a room and start talking to her/him without calling her/his name, does she/he usually look up and pay attention to you?
39. Does she/he ever play imaginative games with another child in such a way that you can tell that each child understands what the other is pretending?
40. Does she/he play cooperatively in games that need some form of joining in with a group of other children, such as hide-and-seek or ball games?

Social Communication Questionnaire (SCQ)

SCQ

Acknowledge & Sign