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Self Assessment > Referral for 48 months and below

Referral for 48 months and below

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Is more withdrawn or more difficult to comfort than other children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