First Responder Form – Autism Odyssey

Be Kind Form for First Responders

Introduce you and your family to your local first responders. e.g. Hello, our family would like to introduce you to our 27-year-old son who is living with autism. Please take a moment to learn about his behaviors so that we can avoid potential misunderstandings.

Your Name*

First Last

Your Email*

Be Kind Caregiver Form for

You have the option to leave this blank and fill it in after printing for privacy reasons.

First Last

Speech Impacted by Autism

Mild
Moderate
Profound

Emergency Contact*

First Last

Emergency Contact Relation

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone*

Backup Contact Name and Phone

Hospital of choice in an emergency:

I take medications

yes, please see my medications form
no

Medications

Drug Name	Milligrams	Dose	When given	Pharmacy

Allergies to medications

Safety Concerns

Self-injurious or aggressive behavior

e.g. hits head, will bite others, runs into traffic

Stranger interaction

e.g. aggressive, fearful, overly trusting

Wandering

I stay by my caregiver’s side
I sometimes unconsciously wander away
I intentionally run away

Additional safety comments

Eating

I have food allergies or sensitivities

yes, please see Food Sensitivity Form
no

Behaviors

If you need to engage, here are the best ways to approach me:

Things that make me anxious or fearful:

The following are triggers for me:

These triggers may invoke the following behaviors:

The following stemming helps me stay regulated:

If I'm having a meltdown, the best thing you can do is:

Name

This field is for validation purposes and should be left unchanged.

Be Kind Form for First Responders

Be Kind Caregiver Form for

Safety Concerns

Eating

Behaviors

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