Intake Questionnaire: English

Revised Intake Questionnaire

General Questions

* = required question

What are your initial concerns about your child?* [narrative]

Has your child been referred to or participated in services including Early Intervention or private therapy before?* [narrative]

What language or languages does your child hear or use in their day-to-day environment?* [narrative]

Medical

Do you have any concerns about your child's health, including medical, growth, and/or nutrition concerns?* [yes+/ no- /uncertain]

Only if there are concerns expressed by the family:

What are your concerns? [narrative]

Does your child have a medical diagnosis or condition that you’d like to share with us? [yes+/ no-/ uncertain] [narrative]

Is your child followed by any specialists? [yes+/ no-/ uncertain] [narrative]

Does your child currently have or are they scheduled for a G tube placement? [yes+/ no-/ uncertain] [narrative]

Was your child born early?* [yes+/ no- /uncertain]  

Only if there are concerns expressed by the family:

If yes, how many weeks early? [numeric value]  

What was your child’s birth weight? [narrative]

Did your child lose weight shortly after birth? [yes+/ no-/ uncertain]

Did your child spend any time in the NICU? [yes+/ no-/ uncertain] [narrative]

Hearing & Vision

Do you have concerns about your child’s hearing and/ or is there a family history of hearing difficulties or loss?* [yes+ / no- / uncertain]

Only if there are hearing concerns expressed by the family:

What are your concerns? [narrative]

Is there a family history of hearing difficulties or loss? [yes+/ no-/ uncertain] [narrative]

Does your child have ear tubes placed or scheduled to be placed? [yes+/ no-/ uncertain] [narrative]

Has your child’s hearing been screened in the past 12 months?* [yes+/ no-/ uncertain]

If yes, when? [narrative]

If yes, what were the results? [narrative]

Has your child had frequent ear infections (3 or more in a 6 month span or more than 4 per year)?* [yes+/ no-/ uncertain] [narrative]

Do you have concerns about your child’s vision and/ or is there a family history of vision impairment or loss?* [yes+/ no-/ uncertain]

Only if there are vision concerns expressed by the family:

Does your child frown or squint when looking at small objects or avoid activities that require close focus? [yes+/ no-/ uncertain]  [narrative]

Does one of  your child’s eyes look different from the other? [yes+/ no-/ uncertain] [narrative]

Have you noticed any involuntary movement of your child’s eyes, such as jiggling up and down or quickly moving from side to side? [yes+/ no-/ uncertain] [narrative]

Has your child’s vision been screened in the past 12 months?* [yes+/ no-/ uncertain] [narrative]  

If yes, when? [narrative]

If yes, what were the results? [narrative]

Is there anything else you would like to share about your child or family before the evaluation?*  [yes+/ no-/ uncertain] [narrative]

This additional set of questions may be asked on the intake call in accordance with the child’s age. They are not required questions.

Birth-3 months

How does your child let you know when they are hungry, tired, or have a soiled diaper? [narrative] [concern: yes+/ no-]

Does your child smile at familiar people? [yes+/ no-] [narrative]

Does your child show a preference for yourself or another caregiver? [yes+/ no-] [narrative]

Does your child calm when held? [yes+/ no-] [narrative]

Does your child seem to look at your face when held? [yes+/ no-] [narrative]

Does your child bring their hands to their mouth? [yes+/ no-] [narrative]

Does your child move both arms and legs? [yes+/ no-] [narrative]

Is your child using their body to make things happen? For example: reaching and kicking. [yes+/ no-] [narrative]

Does your child lose milk while at the bottle or breast? [yes+/ no-] [narrative]

Tell me how your child sleeps and how they get to sleep. [narrative] [concern: yes+/ no-]

3-6 months

Does your child turn towards you when you speak? [yes+/ no-] [narrative]

Is your child making cooing or other sounds? What other sounds are they making? [yes+/ no-] [narrative]

Is your child watching you as you move around the house? [yes+/ no-] [narrative]

Does your child look at their hands with interest? [yes+/ no-] [narrative]

Is your child smiling at you or making other facial expressions? [yes+/ no-] [narrative]

Is your child using their hands and fingers to explore? [yes+/ no-] [narrative]

Does your child bring things to their mouth? [yes+/ no-] [narrative]

Can your child hold their head up? [yes+/ no-] [narrative]

Tell me how your child sleeps and how they get to sleep. [narrative] [concern: yes+/ no-]

6-9 months

Is your child making vowel sounds or babbling with them? For example: ‘ah’, ‘eh’, ‘oh’. [yes+/ no-] [narrative]

How is your child trying to let you know what their needs are? [narrative] [concern: yes+/ no-]

Does your child respond to their name? [yes+/ no-] [narrative]

Does your child enjoy playing games such as peek-a-boo?  [yes+/ no-] [narrative]

Is your child beginning to laugh or show excitement?  [yes+/ no-] [narrative]

Does your child roll from their back to side or stomach-to-side? [yes+/ no-] [narrative]

Does your child pass a toy from one hand to another?  [yes+/ no-] [narrative]

Does your child sit with or without support? [yes+/ no-] [narrative]

Tell me how your child sleeps and how they get to sleep. [narrative] [concern: yes+/ no-]

9-12 months

Is your child making sounds with their voice? What sounds are you hearing? [yes+/no-] [narrative]

Does your child understand more words than they can say or sign? [yes+/ no-] [narrative]

Does your child enjoy doing things over and over again? [yes+/ no-] [narrative]

When you point to something, does your child look at it? [yes+/ no-] [narrative]

Does your child look for you when you are not in the room? [yes+/ no-] [narrative]

Does your child recognize familiar people vs. strangers?  [yes+/ no-] [narrative]

Is your child able to move in and out of sitting by themself?  [yes+/ no-] [narrative]

How does your child move around and explore? [narrative] [yes+/ no-] [narrative]

Tell me how your child feeds themself. [narrative] [concern: yes+/ no-]

What kinds of foods are they eating? For example: soft table foods, baby foods or purees only. [narrative] [concern: yes+/ no-]

Tell me how your child sleeps and how they get to sleep. [narrative] [concern: yes+/no-]

12-15 months

Does your child say a word like ‘mama’, ‘dada’, or ‘ball’ meaningfully? [yes+/ no-] [narrative]

Does your child point to things when named, like body parts or pictures in books? [yes+/ no-] [narrative]

What does your child do to show you ‘no’? [narrative] [concern: yes+ /no-]

What does your child do to greet people or say ‘goodbye’? [narrative] [concern: yes+ /no-]

Does your child show you or others affection? [yes+/ no-] [narrative]

Is your child able to stand without your help? [yes+/ no-] [narrative]

How does your child move around and explore? [narrative] [concern: yes+/ no-]

Is your child trying to do things for themself? [yes+/ no-] [narrative]

Tell me how your child sleeps and how they get to sleep. [narrative] [concern: yes+/ no-]

15-18 months

Does your child try to say words for familiar things or people? [yes+/ no-] [narrative]

How many words is your child saying? [narrative] [concern: yes+/ no-]

Does your child answer yes/ no by shaking their head? [yes+/ no-] [narrative]

Will your child try to problem solve with a toy? [yes+/ no-] [narrative]

Does your child know where familiar items are such as snacks? [yes+/ no-] [narrative]

Has your child recently lost a skill that they once had? [yes+/ no-] [narrative]

Does your child seem to know familiar people? [yes+/ no-] [narrative]

Is your child walking by themself? [yes+/ no-] [narrative]

Does your child stack toys on top of each other? [yes+/ no-] [narrative]

Does your child practice using child-sized fork and spoon to eat? [yes+/ no-] [narrative]

Tell me how your child sleeps and how they get to sleep. [narrative] [concern: yes+/ no-]

18-24 months

Is your child beginning to use two words together? For example: “drink milk”. [yes+/ no-] [narrative]

Can your child follow two-step directions such as “get your shoes'' and “go to the door”? [yes+/ no-] [narrative]

Does your child know what to do with common items around the house? For example, a comb or hairbrush, a spoon or fork, a phone. [yes+/ no-] [narrative]

Is your child engaging in pretend play? For example: driving a car to get gas. [yes+/ no-] [narrative]

Has your child recently lost a skill he/she once had? [yes+/ no-] [narrative]

Does your child notice when others are hurt or upset, like pausing or looking sad when someone is crying? [yes+/ no-] [narrative]

Does your child show a wide variety of emotions? For example: fear, anger, sympathy, modesty, guilt, or joy. [yes+/ no-] [narrative]

Is your child walking and running well? [yes+/ no-] [narrative]

If you hand your child a crayon, pencil, or pen, will they make marks or scribble on paper? [yes+/ no-] [narrative]

Does your child help when getting dressed or undressed? [yes+/no-] [narrative]

Tell me how your child sleeps and how they get to sleep. [narrative] [concern: yes-/no+]

24-30 months

Is your child using short phrases to talk with you? [yes+/ no-] [narrative]

Is your child able to follow directions such as getting shoes when it’s time to go? [yes+/ no-] [narrative]

Does your child play by themselves for a short amount of time? [yes+/ no-] [narrative]

When playing, does your child use one toy to pretend it’s another? For example: using a block for a phone. [yes+/ no-] [narrative]

Is your child interested in playing with other children? [yes+/ no-] [narrative]

Is your child able to explore your home independently? [yes+/ no-] [narrative]

Is your child able to go up and down stairs and curbs at home or in the community? [yes+/ no-] [narrative]

Is your child beginning to draw simple pictures when drawing or coloring? [yes+/ no-] [narrative]

Does your child take off any of their clothes by themselves? [yes+/ no-] [narrative]

Tell me about your child’s toilet learning. [narrative] [concern: yes+/ no-]

Tell me how your child sleeps and how they get to sleep. [narrative] [concern: yes+/ no-]

30-36 months

Is your child using short sentences to talk or sign with you? [yes+/ no-] [narrative]

Can you understand your child when they are talking or signing to you? [yes+/ no-] [narrative]

Can others outside of the family understand your child? [yes+/ no-] [narrative]

Can your child follow two-step directions? [yes+/ no-] [narrative]

Does your child play make believe? For example: using a fork to feed a doll or using a block as a phone. [yes+/ no-] [narrative]

Is your child able to complete simple puzzles and open doors? [yes+/ no-] [narrative]

Has your child recently lost a skill they once had? [yes+/ no-] [narrative]

Is your child able to express their thoughts and feelings? [yes+/ no-] [narrative]

Does your child play next to other children and sometimes plays with them? [yes+/ no-] [narrative]

Does your child play on a toddler sized playground? [yes+/ no-] [narrative]

Is your child able to go up or down the stairs on their own? [yes+/ no-] [narrative]

Has your child had any exposure or experience with play or real scissors? [yes+/ no-] [narrative]

Can your child get dressed and undressed by themselves? [yes+/ no-] [narrative]

Tell me about your child’s toilet learning. [narrative] [concern: yes+/ no-]

Tell me how your child sleeps and how they get to sleep. [narrative] [concern: yes+/ no-]