Online Screening

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Personal Information

Please answer these questions about your child. Keep in mind how your child usually behaves. If you have seen your child do the behavior a few times, but he or she does not usually do it, then please answer no. Please circle yes or no for every question.

Your Name(Required)

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How Can We Reach You?

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Preferred Method of Contact

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Best Time to Contact You(Required)

Your Child's Details

Child's Name

First Last

What's Your Child's Gender?

How Old Is Your Child?

If you point at something across the room, does your child look at it? (FOR EXAMPLE, if you point at a toy or an animal, does your child look at the toy or animal?)(Required)

Yes

Have you ever wondered if your child might be deaf?(Required)

Yes

Does your child play pretend or make-believe? (FOR EXAMPLE, pretend to drink from an empty cup, pretend to talk on a phone, or pretend to feed a doll or stuffed animal?)(Required)

Yes

Does your child like climbing on things? (FOR EXAMPLE, furniture, playground equipment, or stairs)(Required)

Yes

Does your child make unusual finger movements near his or her eyes? (FOR EXAMPLE, does your child wiggle his or her fingers close to his or her eyes?)(Required)

Yes

Does your child point with one finger to ask for something or to get help? (FOR EXAMPLE, pointing to a snack or toy that is out of reach)(Required)

Yes

Does your child point with one finger to show you something interesting? (FOR EXAMPLE, pointing to an airplane in the sky or a big truck in the road)(Required)

Yes

Is your child interested in other children? (FOR EXAMPLE, does your child watch other children, smile at them, or go to them?)(Required)

Yes

Does your child show you things by bringing them to you or holding them up for you to see – not to get help, but just to share? (FOR EXAMPLE, showing you a flower, a stuffed animal, or a toy truck)(Required)

Yes

Does your child respond when you call his or her name? (FOR EXAMPLE, does he or she look up, talk or babble, or stop what he or she is doing when you call his or her name?)(Required)

Yes

When you smile at your child, does he or she smile back at you?(Required)

Yes

Does your child get upset by everyday noises? (FOR EXAMPLE, does your child scream or cry to noise such as a vacuum cleaner or loud music?)(Required)

Yes

Does your child walk?(Required)

Yes

Does your child look you in the eye when you are talking to him or her, playing with him or her, or dressing him or her?(Required)

Yes

Does your child try to copy what you do? (FOR EXAMPLE, wave bye-bye, clap, or make a funny noise when you do)(Required)

Yes

If you turn your head to look at something, does your child look around to see what you are looking at?(Required)

Yes

Does your child try to get you to watch him or her? (FOR EXAMPLE, does your child look at you for praise, or say “look” or “watch me”?)(Required)

Yes

Does your child understand when you tell him or her to do something? (FOR EXAMPLE, if you don’t point, can your child understand “put the book on the chair” or “bring me the blanket”?)(Required)

Yes

If something new happens, does your child look at your face to see how you feel about it? (FOR EXAMPLE, if he or she hears a strange or funny noise, or sees a new toy, will he or she look at your face?)(Required)

Yes

Does your child like movement activities? (FOR EXAMPLE, being swung or bounced on your knee)(Required)

Yes

Score

Additional Information

Is there any other relevant information that could help us better understand how to support you?

Consent

By submitting this form, you acknowledge that the information provided is accurate to the best of your knowledge and give consent for the therapy provider to use this information for the purpose of evaluating and providing appropriate services. Please note that the therapy provider may contact you for further clarification or to gather additional information. Thank you for reaching out. We will do our best to support you in your journey.

Personal Information

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Your Child's Details

Additional Information

Consent

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