Referral for 36 months and below

*For every question please indicate yes or no

Yes	No	Does the child
Yes	No	Understands "who," "what," "where" and "why" questions
Yes	No	Creates long sentences using 5-8 words
Yes	No	Is understood by most people outside of the family most of the time
Yes	No	Talks about the past events (e.g. trip to Grandparents' house, day at childcare)
Yes	No	Tells simple stories
Yes	No	Names one or more colours
Yes	No	Shows affection for favourite playmates
Yes	No	Joins in play with a group of two ot more peers
Yes	No	Engages in multi-step pretend play, including words (e.g. pretending to cook a meal, repair a car, etc)
Yes	No	Listens to stories or music for 5 minutes with adult
Yes	No	Gets up from sqautting position without help
Yes	No	Throws a ball forward fairly straight for three metres
Yes	No	Stands on one foot with momentary balance
Yes	No	Can jump forward from standing on two feet for more than 30 centimetres
Yes	No	Completes an easy puzzle (4-6 pieces)
Yes	No	Copies a circle from a model

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Yes	No	Is more withdrawn or more difficult to comfort than other children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 the objects than people's faces
Yes	No	Has difficulty with feeding, chewing or swallowing
Yes	No	Lack interest toys or typically plays them in an unsusual or repetitive way (e.g. lining up, spinning, opening / closing parts rather than using toy in expected way)
Yes	No	Is preoccupied with unusual interest or topics (e.g. light switches, doors, trains)
Yes	No	Shows 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 a toy vs. the toy itself)
Yes	No	Performs activities in a specific way / certain order and may have temper tantrum if this activity is interrupted
Yes	No	Moves his / her finger, hands or body in odd or repetitive way
Yes	No	Echoes other people's phrases or sentences (e.g. parents says "Put on your shoes", child responds with "Put on your shoes")
Yes	No	Talks in whole phrases or scripts from TV shoes 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)