Is your child biting/hitting?
*
Yes
No
yes
no
Is your child throwing tantrums?
*
Yes
No
yes
no
Is your child expressing themselves non-verbally?
*
Yes
No
yes
no
Total y
Total n
Does your child point and grunt?
*
Yes
No
yes
no
Does your child pull you to what they want?
*
Yes
No
yes
no
Does your child only have a few basic words?
*
Yes
No
yes
no
Total y1
Total n1
Do you notice your child isn’t talking as much as other kids?
*
Yes
No
yes
no
Do you see other kids expressing themselves better?
*
Yes
No
yes
no
Do you think your child is behind based on kids on playground, PK class or play group?
*
Yes
No
yes
no
Total y2
Total n2
Resulty 1
Resultn 2
What Is Your Name?
*
First Name
Last Name
What Is Your E-mail?
*
Should be Empty: