Referral for 30 months and below

*For every question please indicate yes or no

Yes	No	Does the child
Yes	No	Uses 350 words or more
Yes	No	Speaks in sentences of at least 3 words
Yes	No	Uses some adult word-endings (e.g. "two cookies," "bird flying," "I jumped")
Yes	No	Uses action words (e.g. "run," "spill," "fall")
Yes	No	Listens to and understands simple stories and retells familiar stories
Yes	No	Understands concept of size (big vs little), quantity (a little vs a lot)
Yes	No	Uses consonant sounds at the beginning of the words (e.g. big, potty, donut)
Yes	No	Produces words with two or more syllables or beats (e.g. "ba-na-na", "a-pple", "com-pu-ter")
Yes	No	Begins taking short turns with peers, using both words and toys
Yes	No	Shows concern when another child is hurt or sad
Yes	No	Pretend play involves several actions (e.g. feeds doll and then puts her sleep)
Yes	No	Tries to join with you when you sing songs or make rhymes
Yes	No	Recognizes self in mirror or photo
Yes	No	Opens the door by turning the knob
Yes	No	Copies vertical / horizontal line
Yes	No	Can walk up and down the stairs without holding onto wall or railing
Yes	No	Dresses self with a little help
Yes	No	Feeds self with little mess using spoon or fork
Yes	No	Jumps with both feet on the floor

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Yes	No	Is more withdrawn or more difficult to comfort than other children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	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 to 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)