Parents Name
*
Email
*
example@example.com
Phone
*
Please enter a valid phone number.
Child's Date of Birth
-
Month
-
Day
Year
Date
Last Name
Communication
Does your child use words or gestures to communicate their needs?
Yes
No
Does your child imitate sounds, actions, or facial expressions?
Yes
No
Does your child respond when you call their name?
Yes
No
Does your child point to show you something interesting?
Yes
No
Does your child share enjoyment with you (smile at you, look at you to share an experience)?
Yes
No
Social Interaction
Does your child make eye contact during play or interaction?
Yes
No
Does your child play interactively with others (peek-a-boo, taking turns, simple games)?
Yes
No
Does your child show interest in other children or prefer to play alone?
Yes
No
Does your child bring items to you to show you something?
Yes
No
Play & Behavior
Does your child play with toys in expected ways (rolling cars, stacking blocks) or more repetitively?
Yes
No
Does your child line up toys, spin objects, or fixate on specific parts of toys?
Yes
No
Does your child engage in pretend play (feeding a doll, acting out scenarios)?
Yes
No
Repetitive Behaviors & Routines
Does your child have repetitive movements such as hand flapping, rocking, or pacing?
Yes
No
Does your child repeat sounds, phrases, or songs frequently?
Yes
No
Does your child become upset when routines change or transitions occur?
Yes
No
Sensory
Does your child show strong reactions to sounds, textures, lights, or clothing?
Yes
No
Does your child seek sensory input (spinning, jumping, crashing into things)?
Yes
No
Does your child avoid certain sensory experiences (haircuts, brushing teeth, certain foods)?
Yes
No
Daily Living
Is your child eating a wide variety of foods or showing extreme picky eating?
Yes
No
Does your child have difficulty with sleep?
Yes
No
Does your child seem unaware of danger or safety concerns?
Yes
No
Submit
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