The following Communication Form is designed to be included during evaluations by clinicians. It may also be given to a person by a concerned friend.
Note: Communication Forms are checklists designed specifically to support self-knowledge, communication, and self-advocacy. It is a strategy designed and introduced by Catherine Faherty. Creating your own Communication Forms to support communication and self-advocacy – about any topic – is encouraged.
What is the purpose of the Communication Form titled “How Am I Doing”? For people at the intersection of autism and disability, poverty, trauma, sexual violence, survival behavior, unsafe living conditions, etc., personal awareness, understanding, and communicating about any form of abuse and/or violence is extremely complicated. The end result is that help is often inaccessible to the person needing help.
The Communication Form “How Am I Doing?” is offered by Catherine Faherty (Autism Specialist, Author, and Ally) and Jade McWilliams (Autistic Advocate, Activist, Artist). It is our attempt to bring awareness to and facilitate communication in the life of a person experiencing any of these life conditions. The Communication Form (once filled out) is meant to get the attention of those who can help.
“How Am I Doing?” cannot be sold or otherwise distributed for pay. Permission is given for organizations, clinics, nonprofit groups, diagnosticians, and other professionals to use with individuals and clients. Please share widely and freely with agencies, therapists, and service providers, with the intent of supporting authentic communication.
How is the Communication Form “How Am I Doing” to be used? The Communication Form is to be given to a person by a professional and/or friend. It is to help a person reflect on their living situation, and/or to note areas of concern and/or to ask for help, and/or to alert the professional to serious concerns.
It was designed to avoid the difficulty of face-to-face conversation. It is clear, concrete, and without the need to identify, process, or evaluate confusing emotional states. It was written for anyone who may not ask for help, for a variety of reasons. No talking is necessary to identify what is true; it can be completed in silence. It was written specifically for autistic styles of processing and communicating, but can be useful for anyone.
IMPORTANT: Do not mail it out as part of a package of forms prior to an evaluation or an appointment. It is meant to be presented in person – to be filled out when they are alone in a safe place – meaning not in the presence of family members, friends, or other people in the person’s life, even if the other people appear to be supportive.
Please keep in mind that the person filling this out may or may not be aware that there is anything to be concerned about. Some people after filling this out and later learning that there are serious concerns, may experience complicated emotions and/or surprise if you have follow-up questions. Emotions may or may not be expressed outwardly, in a manner that others may understand.
How Am I Doing?
Check all that is true for me. (I do not have to talk about what I have checked.)
About food and housing:
☐ Some days I am very hungry, but there isn’t enough food.
☐ Sometimes I can’t sleep because I am so hungry.
☐ I usually have enough food to eat, every day.
☐ I live alone, most of the time.
☐ One or more people live with me.
☐ I am not sure where I will sleep tonight.
☐ I have my own bed and can sleep alone when I want to.
☐ I have to share a bed most of the time.
☐ I have my own key to where I live.
☐ If I knew that I had a good and safe place to move to, I would want to move there.
☐ There is something else about food or home that I can’t say.
About transportation and going out:
☐ I can go out, away from home, when I want to.
☐ I usually (circle what’s true) – drive – take a bus – taxi – get a ride – walk – other
☐ I can go out to meet a friend when I want to.
☐ I am prevented from going out alone, or with someone else, when I want to.
☐ There is something I want to say, but I can’t say it.
About mood in general:
☐ I have cried in the past week.
☐ I have yelled in the past week.
☐ I have felt calm and peaceful in the past week.
☐ Someone gets angry at me when we are alone, together.
☐ I don’t know when or if the person will get mad at me, and yell.
☐ I don’t know when or if the person will try to hurt me.
☐ Sometimes I hurt myself.
☐ Sometimes I get sweaty and my heart beats very fast. I don’t know why.
☐ There is something else, but can’t say it.
☐ There is something else, but I am not supposed to tell anyone.
About what I have checked (true for me) on this form:
☐ I don’t want to answer questions about what I have checked.
☐ I don’t want to answer questions now, but maybe later today, or on another day.
☐ I might want to answer questions, but I am worried I might get in trouble.
☐ If there are questions, I will try to answer them, after a short break.
☐ Please type your questions (no talking). I will try to answer them by typing. All silently.
Copyright 2018, Catherine Faherty & Jade McWilliams. Permission given for organizations, clinics, nonprofit groups, diagnosticians, and other professionals to use with individuals and clients. This Communication Form cannot be sold or otherwise distributed for pay. Please share widely and freely with agencies, therapists, and service providers, with the intent of supporting authentic communication. See Information Sheet for more info.