Neighborhood – Autism Odyssey

Be Kind Form

Introduction

Sample: Dear Neighbor, My family has recently moved into your neighborhood. We would like to introduce you to our son, Joey. Joey has profound autism and does not speak. You may notice him outside rocking or waving at cars. He is very sweet and enjoys being outside. We encourage friendly interactions and wanted to help bring awareness to behaviors you may not be familiar with.

Your Name*

First Last

Relation to Individual Living with Autism

Other family members of our household

Be Kind Caregiver Form for

First

Your Email*

Address

Street Address Address Line 2 City

Phone*

Backup Contact Name and Phone

Personality

e.g. Joey may act like he doesn’t notice you, but he enjoys it when people say, “Hello!” He often screams loudly. These screams may be joyful or they may be caused by irritation. In almost all cases his screaming doesn’t indicate he’s in trouble or danger. If you suspect he’s in danger, please approach us before calling the police.

Speech impacted by autism:

Mild
Moderate
Profound

Food

I love snacks but have many food intolerances. Please check with my family before giving me anything to eat or drink.

Preferences

I am interested in the following topics:

e.g. trains, dinosaurs, patterns, garbage trucks, etc

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

Things that make me anxious or fearful:

You may know I'm anxious, angry or frustrated, when you see me doing the following:

If I'm having a meltdown, please do not call the police. The best thing you can do is:

My comfort level with animals:

Name

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

Be Kind Form

Be Kind Caregiver Form for

Personality

Food

Preferences

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