• Format: (000) 000-0000.
  • Child's Date of Birth*
     - -

  • Communication

  • Does your child use words or gestures to communicate their needs?
  • Does your child imitate sounds, actions, or facial expressions?
  • Does your child respond when you call their name?
  • Does your child point to show you something interesting?
  • Does your child share enjoyment with you (smile at you, look at you to share an experience)?

  • Social Interaction

  • Does your child make eye contact during play or interaction?
  • Does your child play interactively with others (peek-a-boo, taking turns, simple games)?
  • Does your child show interest in other children or prefer to play alone?
  • Does your child bring items to you to show you something?

  • Play & Behavior

  • Does your child play with toys in expected ways (rolling cars, stacking blocks) or more repetitively?
  • Does your child line up toys, spin objects, or fixate on specific parts of toys?
  • Does your child engage in pretend play (feeding a doll, acting out scenarios)?

  • Repetitive Behaviors & Routines

  • Does your child have repetitive movements such as hand flapping, rocking, or pacing?
  • Does your child repeat sounds, phrases, or songs frequently?
  • Does your child become upset when routines change or transitions occur?

  • Sensory

  • Does your child show strong reactions to sounds, textures, lights, or clothing?
  • Does your child seek sensory input (spinning, jumping, crashing into things)?
  • Does your child avoid certain sensory experiences (haircuts, brushing teeth, certain foods)?

  • Daily Living

  • Is your child eating a wide variety of foods or showing extreme picky eating?
  • Does your child have difficulty with sleep?
  • Does your child seem unaware of danger or safety concerns?
  • Should be Empty: