Parent's Initials
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Child's Initials
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Child's Age
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6 months
7 months
8 months
9 months
10 months
11 months
12 months
13 months
14 months
15 months
16 months
17 months
18 months
19 months
20 months
21 months
22 months
23 months
24 months
EMOTION AND EYE GAZE
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Not Yet
0
Sometimes
1
Often
2
1. Do you know when your child is happy and when your child is upset?
2. When your child plays with toys, does he/she look at you to see if you are watching?
3. Does your child smile or laugh while looking at you?
4. When you look at and point to a toy across the room, does your child look at it?
Total
COMMUNICATION
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Not Yet
0
Sometimes
1
Often
2
5. Does your child let you know that he/she needs help or wants an object out of reach?
6. When you are not paying attention to your child, does he/she try to get your attention?
7. Does your child do things just to get you to laugh?
8. Does your child try to get you to notice interesting objects—just to get you to look at the objects, not to get you to do anything with them?
Total
GESTURES
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Not Yet
0
Sometimes
1
Often
2
9. Does your child pick up objects and give them to you?
10. Does your child show objects to you without giving you the object?
11. Does your child wave to greet people?
12. Does your child point to objects?
13. Does your child nod his/her head to indicate yes?
Total
COMMUNICATION COMPOSITE SCORE
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SOUNDS
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Not Yet
0
Sometimes
1
Often
2
14. Does your child use sounds or words to get attention or help?
15. Does your child string sounds together such as uh oh, mama, gaga, bye bye, bada?
*
None
0
One to Two
1
Three to Four
2
Five to Eight
3
Over Eight
4
16. About how many of the following consonant sounds does your child use: ma, na, ba da, ga, wa, la, ya, sa, sha?
Total
WORDS
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None
0
One to Two
1
Three to Four
2
Five to Eight
3
Over Eight
4
17. About how many different words does your child use meaningfully that your would recognize (such as baba for bottle; or gaggie for doggie)?
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Not Yet
0
Sometimes
1
Often
2
18. Does your child put two words together (for example, more cookie, bye bye Daddy)?
Total
EXPRESSIVE SPEECH COMPOSITE SCORE
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UNDERSTANDING WORDS
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Not Yet
0
Sometimes
1
Often
2
19. When you call your child’s name, does he/she respond by looking or turning toward you?
*
None
0
One to Two
1
Three to Four
2
Five to Eight
3
Over Eight
4
20. About how many different words or phrases does your child understand without gestures? For example, if you say “where’s your tummy,” “where’s Daddy,” “give me the ball,” or “come here,” without showing or pointing, your child will respond appropriately.
Total
OBJECT USE
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Not Yet
0
Sometimes
1
Often
2
21. Does your child show interest in playing with a variety of objects?
22. Does your child pretend to play with toys (for example, feed a stuffed animal, put a doll to sleep, put an animal figure in a vehicle)?
*
None
0
One to Two
1
Three to Four
2
Five to Eight
3
Over Eight
4
23. About how many of the following objects does your child use appropriately: cup, bottle, bowl, spoon, comb or brush, toothbrush, washcloth, ball, toy vehicle, toy telephone?
*
None
0
Two
1
Three to Four
2
Five or more
3
24. About how many blocks (or rings) does your child stack?
Total
SYMBOLIC COMPOSITE SCORE
CSBS-DP TOTAL SCORE
Where did you hear about us?
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Are you located in the Atlanta-Metro area?
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