Pre-screen/evaluation Form

This form is intended to provide some additional information about your child's needs, and to eval0uate 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.

Fields in bold are required

Your Name:
Email:
Phone: (000-000-0000)
  Best time to call:
   
Child's Name:
Child's Age:
  Almost
Always
Often Sometimes Seldom Never
When someone looks at or speaks to your child, does your child look at the speaker?
Does your child avoid physical contact (i.e., hugs, pats on the back, being held?)
Does your child invite other children to play with him/her? Initiate conversations with other children?
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")?
Do you feel that your child is more apprehensive than other children when speaking to or playing with someone new?
Does your child engage in pretend-play?
Does your child become anxious when routines are changed unexpectedly (school day ending early, different parent picking up from school)?
Does you child take turns in games and conversations?
Does your child maintain topic during conversation (speaks about things relevant to the topic, adds information, does not change topic)?
Does your child understand or tell jokes?
Does your child ask for help or clarification if confused or having difficulty?
Is your child able to use appropriate language during conflicts?
Does your child negotiate appropriately (makes "deals" for bedtime, snacks, etc., rather than asking multiple times)?
Does your child ask others to change their actions (please move, stop tapping)?
Does your child respond to teasing, anger, failure, or disappointment appropriately?
Does your child read social situations (not a good time to talk, how others are feeling)?
Does your child use and understand facial expressions, body language, and intonation (sarcasm, etc.)?
Does your child have difficulty managing his/her anger?
Does your child have difficulty understanding and expressing his/her emotions?

Does your child throw tantrums?

Can your child be redirected ("Madison is using that toy now, would you like to play with this one?") or use calming strategies (deep breaths, count to 10, etc.)?
 
  More
Mature
As
Mature
Less
Mature
   
Would you say that your child is more mature, less mature, or as mature, as his/her peers?    
   
Please give a brief description of your child’s educational and social difficulties:
   
Additional Comments:
(optional)
   
 
Copyright 2010: PALSS of Washington, LLC. All Rights Reserved
Site Design  ::  Studio Chazerai