Autism Spectrum Disorder (Asd) Safety Planning Packet (Page 4 of 4) in pdf

(ASD) Emergency Contact Form

Date Submitted: Department of Transportation: ______ School: ________

Other Relevant Medical Conditions in addition to Autism Spectrum Disorder (check all that apply)

____No Sense of Danger

___Blind ___Deaf __Non-Verbal ___Intellectual Disability

____Attracted to Water ___ Prone to Seizures ___ Other

If Other, Please Explain:

________________________________________________________________________________________________

Allergies:

_________________________________________________________________________________________________

________________________________________________________________________________________________

Prescriptions Medications needed:

__________________________________________________________________________________________________

________________________________________________________________________________________________

Sensory or dietary issues, if any:

__________________________________________________________________________________________________

Calming Methods or other important info for FIRST RESPONDERS:

___________________________________________________________________________________________________

Inclination for wandering behaviors or characteristics that may attract attention:

___________________________________________________________________________________________________

Likes/Dislikes (recommended approach and de-escalation techniques):

___________________________________________________________________________________________________

Other Special Considerations:

___________________________________________________________________________________________________

Autism Spectrum Disorder (Asd) Safety Planning Packet Page 4