Screening Questionnaire: Age 8-11
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
*
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. Participates in team games
Yes
No
2. Walks backwards heel-toe
Yes
No
3. Skips forward
Yes
No
4. Kicks a ball while moving/changing directions
Yes
No
5. Completes somersaults
Yes
No
6. Completes multiple sit ups
Yes
No
7. completes multiple push-ups
Yes
No
8. Participates in skipping rope independently
Yes
No
9. Completes Jumping Jacks
Yes
No
10. Can ride bicycle without training wheels
Yes
No
Additional Physical Therapy comments or concerns:
Occupational Therapy
Occupational Therapy
1. Uses microwave safely to heat up meals without supervision
yes
no
2. Completes money transactions and identifies correct change after purchase
yes
no
3. Has stranger awareness when asked to leave a location with an unfamiliar person
yes
no
4. Loads Dishwasher or washes dishes by hand independently
yes
no
5. Obtains items needed to complete grooming activities independently
yes
no
6. Follows verbal/written directions to a nearby location
yes
no
7. Follows simple road safety rules
yes
no
8. Sets table independently
yes
no
9. Completes homework in time
yes
no
10. Brings all school materials needed for homework
yes
no
Additional Occupational Therapy comments or concerns:
Speech Therapy
Speech Therapy
1. What is your child's communication method?
Whines, screams, cries
Gestures (e.g. push, pull, grab, wave)
American Sign Language
AAC/Speech Generating device
Single words
Two word combinations (e.g. want milk, eat cereal, puppy eat, go bye bye )
Three word Phrases (e.g. Puppy drink water, daddy go park)
Full sentences
Produces all developing sounds clearly
Speech is understandable, but makes mistakes with multisyllabic or complex words
2. Makes predictions about stories
Yes
No
3. Understands and considers others’ intentions and feelings
Yes
No
4. Can summarize main points and provide the main idea of a story
Yes
No
5. Uses nonlinguistic and nonverbal behaviors (posture, gestures) appropriately
Yes
No
6. Uses most morphological markers consistently (e.g. pronouns, past tense -ed, irregular past tense, regular and irregular plurals)
Yes
No
7. Can use conjunctions to elaborate a sentence structure (e.g. and, but, or, because)
Yes
No
8. Maintains topic with an individual or small group through several turns
Yes
No
9. Reads, understands and answers WH questions about grade-level material
Yes
No
10. Any feeding difficulties?
Transitioning from liquids to puree
Transitioning from puree to solids (soft, mechanical)
Coughs with solids/liquids
Choking or gagging
Reflux
Regurgitation of solids/liquid through nose
Difficulty with chewing
Picky eater
NG, J or G-tube fed
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 button
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