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Self Assessment > Referral for 36 months and below

Referral for 36 months and below

*For every question please indicate yes or no
YesNoDoes the child
Understands "who," "what," "where" and "why" questions
Creates long sentences using 5-8 words
Is understood by most people outside of the family most of the time
Talks about the past events (e.g. trip to Grandparents' house, day at childcare)
Tells simple stories
Names one or more colours
Shows affection for favourite playmates
Joins in play with a group of two ot more peers
Engages in multi-step pretend play, including words (e.g. pretending to cook a meal, repair a car, etc)
Listens to stories or music for 5 minutes with adult
Gets up from sqautting position without help
Throws a ball forward fairly straight for three metres
Stands on one foot with momentary balance
Can jump forward from standing on two feet for more than 30 centimetres
Completes an easy puzzle (4-6 pieces)
Copies a circle from a model
YesNoHas anyone noticed whether the child
Has lost any previously obtained skills
Has inconsistent / no response when name is called
Rarely engages socially (e.g. smiling, eye contact)
Is more withdrawn or more difficult to comfort than other children
Is more interested in looking at the objects than people's faces
Has difficulty with feeding, chewing or swallowing
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)
Is preoccupied with unusual interest or topics (e.g. light switches, doors, trains)
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)
Performs activities in a specific way / certain order and may have temper tantrum if this activity is interrupted
Moves his / her finger, hands or body in odd or repetitive way
Echoes other people's phrases or sentences (e.g. parents says "Put on your shoes", child responds with "Put on your shoes")
Talks in whole phrases or scripts from TV shoes or books when these do not seem relevant to the situation
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"))
Has an unusual voice quality (e.g. nasal, hoarse, breathy)