Referral for 12 months and below

*For every question please indicate yes or no

Yes	No	Does the child
Yes	No	Follows simple 1-step directions e.g. "sit down"
Yes	No	Looks accross the room to a toy when adult points to it
Yes	No	Uses specific gestures to communicate (e.g. waves hi/bye, shakes head "no")
Yes	No	Uses three or more "words" (same sounds to indicate same object or person)
Yes	No	Brings / extends toys to you
Yes	No	Gets your attention using sounds, gestures and pointing while looking at your eyes
Yes	No	Consistently points to request
Yes	No	"Performs" for social attention and praise
Yes	No	Plays social games with you (e.g. "Peek-A-Boo", "patty cake")
Yes	No	Combines a lot of sounds together as though talking (e.g. "abada badu abee")
Yes	No	Shows interest in simple picture books
Yes	No	Turns pages of books a few at a time
Yes	No	Removes objects from containers (e.g. food, block, toys)
Yes	No	Helps a little while being dressed (e.g. extends arm to put in sleeve)
Yes	No	Lifts cup to mouth with two hands to drink
Yes	No	Picks up and eats finger foods
Yes	No	Stands alone for 2 seconds or more
Yes	No	Walks sideways holding on to furniture
Yes	No	Lowers self from standing with control, not falling on bottom

Yes	No	Has anyone noticed whether the child
Yes	No	Has lost any previously obtained skills
Yes	No	Has inconsistent / no response when name is called
Yes	No	Rarely engages socially (e.g. smiling, eye contact)
Yes	No	Is more withdrawn or more difficult to comfort than other children
Yes	No	Is more interested in looking at objects than people's faces
Yes	No	Has any difficulty with feeding, chewing or swallowing