Language
English (US)
Español
Age 0-1: Screening Questionnaire
Please fill out the sections that are relevant to your child. This will help us gather important information about your child's development.
Caregiver's Name
*
First Name
Last Name
Child's Diagnosis (If applicable)
*
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Preferred Contact Method
*
Phone Call
Text
Email
Physical Therapy
Physical Therapy
1. While laying on tummy, pushes self with both arms to lift head
Yes
No
2. Lifts head/chin while laying on back
Yes
No
3. Stands up for a 1-2 sec
Yes
No
4. Sits independently on the floor
Yes
No
5. Pulls up from furniture to stand up
Yes
No
6. Walks around while holding onto furniture
Yes
No
7. Plays while kneeling
Yes
No
8. Uses half kneeling to stand up
Yes
No
9. Rolls self from laying on back, to laying on belly
Yes
No
10. Crawls forwards and backwards
Yes
No
Additional Physical Therapy comments or concerns:
Occupational Therapy
Occupational Therapy
1. Holds own bottle with two hands
yes
no
2. Feeds self with fingers or spoon
yes
no
3. Cooperates with dressing by moving arms/legs
yes
no
4. Turns eyes and head towards sounds(including name)and/or familiar voices
yes
no
5. Finds hidden objects (ex. finds hidden toy/food under cover)
yes
no
6. Pokes toys/foods with index finger
yes
no
7. Grasps tiny objects (ex. cereal) with index finger and thumb
yes
no
8. Moves toys from one hand to opposite hand while playing
yes
no
9. Smiles back to a smile from a familiar adult
yes
no
10. While sitting, reaches for objects with two or one hand
yes
no
Additional Occupational Therapy comments or concerns:
Speech Therapy
Speech Therapy
1. Looks toward speaker and smile when someone is talking to him/her
Yes
No
2. Vocalizes back when hearing voices
Yes
No
3. Appears to understand words such as "Daddy", "Mommy" or "bye-bye"
Yes
No
4. Follows simple routine commands such as "Come here!" or "Let's go!"
Yes
No
5. At least half of the time stops or changes direction when told "No" or "Stop that"
Yes
No
6. Uses exclamations such as "Uh Oh!" or "Unh-Unh"
Yes
No
7. Tries to imitate words heard from you or other people nearby
Yes
No
8. Sometimes plays games such as "Pat-a-cake" or "Peek-a-boo"
Yes
No
9. Please check current vocalization stage:
Cooing/Vowel-like sounds (e.g. "oooo", "aaaa")
Single-syllable speech sounds (e.g. "bah", "mah")
Reduplicated babbling- Repetition of same syllables (e.g. "da-da-da'')
Variegated babbling- Mixing different syllables (e.g. "ba-da-ma")
Jargon- Complex babbling with rhythm and tone
First words
10. Any feeding difficulties?
Sucking/Nursing
Transitioning from bottle to baby food
Choking or gagging
Reflux
Regurgitation of solids/liquid through nose
Difficulty with chewing
Additional Speech Therapy comments or concerns:
Applied Behavior Analysis
Applied Behavior Analysis
Please describe how your child communicates with you (words, pictures, signs, assistive technology). Example 1: My child can use 50 words to ask for items or activities. Example 2: My child typically pulls me towards the items they want.
Please describe any challenging behaviors your child has exhibited when faced with difficult situations such as but not limited to being told no or asked to complete a non-preferred task. Example 1: When I tell my child that it is time for a bath, they typically run away and refuse to come. Example 2: When my child loses a game, they typically will cry and throw the game pieces.
Please describe the main goals you have for your child.
Submit
Submit
Should be Empty: