Child's Information
Child's First Name
*
Child's Middle Initial
*
Child's Last Name
*
Child's Date of Birth
*
Gender
*
Male
Female
Person filling out questionnaire
First Name
*
Middle Initial
*
Last Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
Please enter a valid phone number.
Other Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Relationship to child
*
Parent
Guardian
Teacher
Other
Grandparent/Relative
Foster Parent
Child Care Provider
Other
People Assisting Questionnaire Completion
Type a question
*
Often or Always
Sometimes
Rarely or Never
Checck if this is a concern
1. Does your child look at you when you talk to him/her?
2. Does your child cling to you more than you expect?
3. Does your child talk or play with adults he/she knows well?
4. When upset, can your child calm him/herself down within 15 minuets?
5. does your child like to be hugged or cuddled?
6. does your child seem too friendly with strangers?
7. Does your child settle him/herself down after exciting activities?
8. Does your child cry, scream, or have tantrums for long periods of time?
9. Does your child seem interested in things around him/her such as people, toys, and foods?
10. Does your child stay dry during the day?
111. Does your child have eating problems? For example, does he/she stuff food, vomit, eat things that are not food, or_____? (Please describe below)
12. Do you and your child enjoy mealtimes together?
13. Does your child do what you ask him/her to do?
14. Does your child seem happy?
15. Does your child sleep at least 8 hours in a 24 hour period?
16. Does your child seem more active than other children their age?
17. Does your child use words to tell you what he/she wants?
18. Does your child stay with activities he/she enjoys for at least 10 minuets? (other than watching shows or videos, or playing with electronics)
19. Does yourchild use words to describe their feelings and the feelings of others? For example, do they say, "i'm happy", "I don't like that", or "she's sad"
20. Does your child move from one activity to the next with little difficulty? (for example, from playtime to mealtime)
21. Does your child explore new places, such as a par or a friends home?
22. Does your child do things over and over and get upset when you try to stop him? For example, does he/she rock, flip his/her hands. spin, or ____? (Please describe below)
23. Does your child hurt him/herself on purpose?
24. Does your child follow rules at home or at child care?
25. Does your child destroy or damage things on purpose?
26. Does your child stay away from dangerous things, such as fire and moving cars?
27. Can your child name a friend?
28. Does your child show concern for other people's feelings? For example, does he/she look sad when someone is hurt?
29. Do other children like to play with your child?
30. Does your child like to play with other children?
31. Does your child try to hurt other children, adults, or animals?(for example, by kicking or biting)
32. Does your child show an unusual interest or knowledge of sexual language or activity?
33. Does your child wake three or more times during the night?
34. Is your child too worried or fearful? If "Sometimes" or "often or always" please describe below.
35. Does your child have simple back and forth conversations with you? for example,
Parent: "it's raining"
child: "and cold outside"
Parent: "let's get your coat"
child: "I got it"
36. Has anyone shared concerns about your child's behaviors? If "Sometimes" or "often or always" please explain below
Please Describe from question 11
Please describe form question 22
Please describe from question 34
Please describe from question 36
Do you have concerns about your child's eating, sleeping, or toileting habits? If yes, Please explain below.
*
Yes
No
If yes, please explain
Does anything about your child worry you? If yes, please explain below
*
Yes
No
If yes, please explain
What do you enjoy about your child?
*
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