Referral for 18 months and below

*For every question please indicate yes or no

Yes	No	Does the child
Yes	No	Uses at least 20 words consistently even if not clear (e.g. labelling food, toys, people)
Yes	No	Makes at least 4 different consonant sounds (e.g. p, b, m, n, d, g, w, h)
Yes	No	Imitates words and gestures
Yes	No	Responds with words or gestures to simple questions (e.g. "where's teddy?", "what's that?")
Yes	No	Understands the concepts of "in & out", "off & on"
Yes	No	Points to three or more body parts when asked
Yes	No	Points to familiar pictures using one finger
Yes	No	Enjoys being read to and sharing simple books with you
Yes	No	Demonstrates some pretend play with toys (e.g. gives teddy a drink, pretends a bowl is a hat)
Yes	No	Walks alone (feet may have wide gait)
Yes	No	Walks up and down stairs with assistance
Yes	No	Climbs onto a low step, table or stool
Yes	No	Likes to retrieve and carry objects
Yes	No	Takes off own socks and hat
Yes	No	Stacks 3 blocks
Yes	No	Brings spoon to mouth in attempts to self feed

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	Tries to get your attention to show you what they are interested in
Yes	No	Consistently points to what he / she wants when it is out of reach
Yes	No	Looks for a toy when asked where it is or you point to it
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Yes	No	Is more withdrawn or more difficult to comfort than other children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	When eating has sensitivity to different textures OR difficulty chewing or swallowing
Yes	No	Lacks interest in toys or typically plays with them in an unusual way (e.g. lining up, spinning, opening / closing parts rather than using the toy as a whole)
Yes	No	Shows an intense interest in letters or numbers to the exclusion of a more typical way of interacting with an object (e.g. focusing on the words rather than the pictures in a book, or on the letters written on an toy vs. the toy itself)
Yes	No	Performs activities in a special way / certain order and may have a temper tantrum if this activity is interrupted
Yes	No	Moves his / her fingers, hands or body in an odd or repetitive way
Yes	No	Echoes other people's phrases or sentences (e.g. parent say "Put on your shoes" child responds "Put on your shoes")
Yes	No	Talks in whole phrases or scripts from TV shows or books when these do not seem relevant to the situation
Yes	No	STUTTERS: Parents report child "stutters" using repetitions of words (e.g. "I I I" or syllables (e.g. "dadadaddy"), sound prolongations(e.g. mmmommmy) or blocks (e.g. "b---all"))
Yes	No	Has an unusual voice quality (e.g. nasal, hoarse, breathy)