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PRE-ASSESSMENT PACKET Wv2.1

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196 views6 pages

PRE-ASSESSMENT PACKET Wv2.1

Uploaded by

amy tuggle
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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RESEARCH AUTISM ASSESSMENT

Tel: (505) 459-9813


Email: [email protected]

Thank you for your interest in participating in this research autism assessment. If you would like to
continue with the process, please complete the listed items below.

Once you have completed these items, email the results and completed forms and documents to
[email protected]. Please also complete the minimum donation to Wilderwood of
$500. This can be made by check or money order (payable to Wilderwood Equine Therapy and
Rescue) or via PayPal at this link. Once these items have been received, an assessment appointment
will be scheduled. We strive to schedule the appointment within 2-4 weeks of receiving all the
documentation and donation.

A. Consent Form and Intake Form (included in this packet).


B. Pre-Screening Assessments (3): Click on the links below to access.
1. Autism Quotient Assessment
2. CAT-Q Assessment
3. RAADS-R Assessment
C. Medical, Employment, Education History
Please complete the form (included in this packet) relating to medical, employment, and education
history. We only require the information that is asked.
D. Third-Party Statement about Strengths and Challenges
A third party statement with observations made about your strengths and challenges. This
statement can come from a partner, parent, friend, colleague, sibling, counselor, neighbor, pastor –
anyone of your choosing who knows you well enough to write a statement.
E. Narrative
Please prepare a personal/autobiographical narrative that is a minimum of 5-6 typed pages
describing your childhood, teen, and adult memories. Include challenges and difficulties as well as
your talents, achievements, and successes. Occasional use of bullet points is OK, but the narrative
should mostly be written in prose/paragraphs. Try to illustrate these memories with specific
examples that bring your past to life. Please submit the narrative as either a Word or PDF
formatted document. We cannot work with Pages files.

If you have any questions, please don’t hesitate to ask. We look forward to meeting with you soon.

With regards,

Rebecca Evanko, Ph.D


RESEARCH CONSENT AGREEMENT

Please read, then sign the following Consent Agreement. There are two pages, front and back.

I am seeking a diagnosis assessment for the possibility of autism from Dr. Mark Evanko and Dr.
Rebecca Evanko. I understand that the process will involve the following steps:

1. I will be asked to read and sign this Consent Form.


2. I will be asked to make a donation to Wilderwood for the assessment prior to my appointment.
3. I will have the opportunity to ask questions for clarification about the diagnostic testing prior
to my appointment.
4. I will be asked to provide accurate details of my medical, family, employment, educational,
social and/or other history relating to my life.
5. I will be asked to complete three pre-screening online assessments and provide the results by
email prior to my appointment. There is no cost involved to me in taking the assessments other
than my own time and access to computer/Internet. These assessments must have been taken
within a 90-day window prior to my appointment. These pre-screening assessments are:
a. Autism Quotient Assessment
b. CAT-Q Assessment
c. RAADS-R Assessment
6. My assessment appointment will be conducted via Zoom.
7. The assessment appointment may take between one to four hours (two hours is average).
8. During my assessment appointment, I will be asked to complete further assessments.
Assessments administered during the appointment may include any or all of the following. I
understand that I should not take any of the assessments listed below before my appointment:
a. Beck Anxiety Inventory
b. Beck Depression Inventory
c. GQ-ASC
d. SRS-2
The fifth assessment item, the WRADIANCE (©2021, 2024), is a copyrighted research
assessment tool in progress, and is developmental and experimental. The assessment involves
responses to 150 statements. If I am uncomfortable with any question or do not wish to
answer, I may choose not to respond without any prejudice or potential impact on my
assessment. My participation in this assessment will be used to research, strengthen, and re-
evaluate this developing proprietary assessment tool and protocol for potential publication
and broader use and application.
9. I understand that Wilderwood Equine Therapy and Rescue offers programs for autistic
adults, but that this research diagnostic assessment is a separate process and there is no
obligation or expectation about my participation in any program now or in the future.
10. I will receive a written statement of results of my assessment within one week of attending
my assessment appointment.
2

By signing this form, I understand the following:

• In consulting with Dr. Mark Evanko and Dr. Rebecca Evanko, I am solely seeking a diagnostic
assessment for the possibility of autism and that no other diagnosis is made or considered.
• I agree to participate in the process of assessment and provide the requested information and
supporting documents to the best of my ability and recollection.
• The information I provide and the assessment in which I participate is in no way intended as a
course of treatment and does not serve to establish any client-provider relationship.
• In the event that another diagnosis apart from autism is considered a possibility during or
following the assessment process, I understand that it may be recommended for me to see
another provider or providers for follow-up and potential treatment and/or therapy and
that I am solely responsible for following up with any such recommendations.
• I agree to hold harmless and indemnify Dr. Mark Evanko, Dr. Rebecca Evanko, and
Wilderwood Equine Therapy from any outcome or result of this diagnostic assessment.
• Any identifying information I provide in relation to this assessment will be kept confidential
and, unless used for the purposes of academic research, will not be shared or disseminated
without my express consent. In the case of academic research, which may include publication
of results or analysis in academic journals or other media and/or publication(s), any private or
identifying information relating to me will be removed.
• I understand that the Drs. Evanko donate their time to perform these assessments and that
they ask that a minimum donation of $500 is made to Wilderwood to support its programs,
research, services, and horses – and that I can request which area I want my donation to go.
All reasonable efforts will be made to apply the donation to the requested area subject to
program needs.

My signature below attests to my understanding of the terms and agreements outlined above and my
consent to undertake a diagnostic assessment with Dr. Mark Evanko and Dr. Rebecca Evanko. I have
been given opportunity to ask questions and had them answered to my satisfaction.

Name:

Signature:

Date
3

INTAKE FORM
Please complete all sections and fields as completely as possible.

Name:

Preferred Name:

Telephone:

Address:

City: State: Zip:

Email:

DOB: Age: Sex at Birth: Gender:

Pronoun:

Occupation:

Hours worked per week: Children: Relationship Status:

Education: Please select

Race/Ethnicity:

Why are you seeking a diagnosis?

Previous therapies or interventions


4

MEDICAL, EMPLOYMENT, EDUCATION HISTORY


Medical History: Please indicate on the list below what you have been officially diagnosed
with. If you identify with a diagnosis, but have not been officially diagnosed, please indicate
“self-diagnosed.” If there is a mental health diagnosis not listed here, please include it.

Diagnosis Official Self Diagnosis Official Self


ADHD Irritable Bowel Syndrome
Anxiety Major Depressive Disorder
Bipolar II PMDD
Borderline Personality PTSD
Complex PTSD OCD
Depression Raynaud’s Syndrome
Ehlers-Danlos Syndrome Social Anxiety Disorder
Generalized Anxiety
GERD (Reflux)

Employment History: Please list your employment history, starting with your current or most
recent workplace. List the time you were there (in months or years), then summarize any
difficulties you had in the workplace.

Time employed Summarize difficulties encountered during employment


Example: 6 months Example: Employer was not acting ethically; difficulty relating to co-workers
5

Please indicate which level(s) of education you have attained:


Education Major or Area of Study (if applicable)
High School Diploma
GED
Trade School
Associate’s degree
Certification
Bachelor’s degree
Master’s degree
Doctoral degree
Professional degree
Provide any additional degrees or certifications below

Completion of Application

Please submit this completed form, along with your third party statement and 5-6 page typed
narrative saved in PDF format. You may email the documentation to:

[email protected]

or you can mail it to:

Wilderwood, 7 Wildwood Lane, Peralta, NM, 87042.

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