Referral for 48 months and below

*For every question please indicate yes or no

Yes	No	Does the child
Yes	No	Follows directions involving 3 or more steps (e.g. "get some paper, draw a picture, give it to Mom")
Yes	No	Use adult-type grammar
Yes	No	Tells stories with clear beginning, middle and end
Yes	No	Demonstrates increasingly complex imaginative play, using words, actions and interactions with peers
Yes	No	Speaks clearly enough to be understood by strangers almost all of the time
Yes	No	Enjoys rhyming (e.g. cat, bat, hat) and singing children's songs
Yes	No	Participates in turn taking activities / games with 1-2 other peers (e.g. catch, snakes and ladders)
Yes	No	Runs, stops, and starts without falling / good coordination
Yes	No	Walks upstairs alternating one foot to each step, without holding the wall or railing
Yes	No	Draws the cirlce and a square
Yes	No	Cuts across paper with small scissors
Yes	No	Put shoes on correct feet
Yes	No	Toilet trained
Yes	No	Dresses and undresses without help
Yes	No	Washes and dries hands without assistance
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Yes	No	Is more withdrawn or more difficult to comfort than other children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)