Referral for 24 months and below

*For every question please indicate yes or no

Yes	No	Does the child
Yes	No	Uses 100 words or more
Yes	No	Uses at least two pronouns (e.g. "you", "me", "mine")
Yes	No	Consistently combines 2 to 4 words in short phrases (e.g. "Daddy hat", "Truck go down")
Yes	No	Words are understood by others half the time
Yes	No	Forms words and sounds easily and effortlessly
Yes	No	Follows two-step directions (e.g. "Go find your teddy and show it to grandma")
Yes	No	Enjoys being around and playing with other children (e.g. sharing or to offering toys to peers)
Yes	No	Begins to imitate peers; actions and words
Yes	No	Holds the book the right way up and turns pages one at a time
Yes	No	Pretends by acting out daily and special routines with toys (e.g. cooking a meal or a birthday party)
Yes	No	Can run or walk fast
Yes	No	Walks downstairs holding only onto parent's finger
Yes	No	Kicks ball forward
Yes	No	Tries to undress self (e.g. takes off / opens coat, pulls down pants)
Yes	No	Can throw a small ball overhand
Yes	No	Scribbles with crayons / marks paper
Yes	No	Feeds him / herself with a spoon, spilling little

Yes	No	Has anyone noticed whether the child
Yes	No	Has lost any previously obtained skills, language or social skills
Yes	No	Does not respond consistently or at all 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Yes	No	Is more withdrawn or more difficult to comfort than other children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	When eating, has sensitivity / aversions to different textures OR difficulty chewing or swallowing
Yes	No	Lacks interest in toys or typically play with them in an unusual or repetitive way (e.g. lining up, spinning, opening / closing parts rather than using the toy in the expected way)
Yes	No	Is preoccupied with unusual interests or topics (e.g light switches, doors, fans, trains)
Yes	No	Is preoccupied with unusual interests or topics (e.g. light switches, doors, fans, trains)
Yes	No	Shows an intense interest in letters or numbers and / or some ability to recognize untaught printed words
Yes	No	Moves his / her fingers, hands or body in an odd or repetitive way
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)