Pre-screen / evaluation This form is intended to provide some additional information about your child's needs, and to evaluate whether or not your child would be a good fit for our program. All responses will be held in the strictest confidence and will not be used for any other purpose than evaluation and intake. If you are evaluating more than one child, please complete a separate form for each. Your name*PrefixFirstLastSuffixEmail*Enter EmailConfirm EmailPhoneBest time to call...weekdays 9a-5pweekdays 5a-9pweekends 9a-9pChild's name*Child's age*...6 yrs old7 yrs old8 yrs old9 yrs old10 yrs old11 yrs old12 yrs oldMakes eye contact*When someone looks at or speaks to your child, does your child look at the speaker?Regularly Often Sometimes Seldom Never Avoids physical contact*When someone looks at or speaks to your child, does your child look at the speaker?Regularly Often Sometimes Seldom Never Initiates play/conversation*Does your child invite other children to play with him/her? Initiate conversations with other children?RegularlyOftenSometimesSeldomNeverPretend-play*Does your child engage in pretend-play?RegularlyOftenSometimesSeldomNeverFollows others' leads during play*Does you child follow others' leads during play (in a game of pretending, does your child pretend the same category/events and follow willingly if another child changes the "rules")?RegularlyOftenSometimesSeldomNeverApprehensive with new people*Do you feel that your child is more apprehensive than other children when speaking to or playing with someone new?RegularlyOftenSometimesSeldomNeverUncomfortable with change*Does your child become anxious when routines are changed unexpectedly (school day ending early, different parent picking up from school)?RegularlyOftenSometimesSeldomNeverTaking turns*Does you child take turns in games and conversations?RegularlyOftenSometimesSeldomNeverStays on topic*Does your child maintain topic during conversation (speaks about things relevant to the topic, adds information, does not change topic)?RegularlyOftenSometimesSeldomNeverTells/understands jokes*Does your child understand or tell jokes?RegularlyOftenSometimesSeldomNeverAsks for help*Does your child ask for help or clarification if confused or having difficulty?RegularlyOftenSometimesSeldomNeverUses language appropriately*Is your child able to use appropriate language during conflicts?RegularlyOftenSometimesSeldomNeverNegotiates appropriately*Does your child negotiate appropriately (makes "deals" for bedtime, snacks, etc., rather than asking multiple times)?RegularlyOftenSometimesSeldomNeverResponds appropriately*Does your child respond to teasing, anger, failure, or disappointment appropriately?RegularlyOftenSometimesSeldomNeverAsks others to change actions*Does your child ask others to change their actions (please move, stop tapping)?RegularlyOftenSometimesSeldomNeverInterprets social situations*Does your child read social situations (not a good time to talk, how others are feeling)?RegularlyOftenSometimesSeldomNeverUses/understands non-verbal cues*Does your child use and understand facial expressions, body language, intonation (sarcasm, etc.) and other non-verbal cues?RegularlyOftenSometimesSeldomNeverDifficulty with emotions*Does your child have difficulty understanding and expressing his/her emotions, and/or have difficulty managing his/her anger?RegularlyOftenSometimesSeldomNeverTantrums*Does your child throw tantrums?RegularlyOftenSometimesSeldomNeverMaturity level*Would you say that your child is more mature, less mature, or as mature, as his/her peers?More matureAs matureLess matureChallenges/difficulties*Please give a brief description of your child’s educational and social challenges/difficulties.
