concerns are age include inappropriate that is causing problems in in serious and / or repeated appropriate or this comments to others or the life. Child may be sanctions to the child. child’s information is unknown to unusual behavior that results intentionally getting in me. Child is under the age in sanctions to the child. trouble in school or at home. of 3. If the needs / functioning fall within a shaded box, explain why: child’s C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages Birth to 5) III-1. Overall Development (PAST 30 DAYS) Child’s Child has no developmental Child has some problems Child has developmental Child has severe and problems. Any concerns are with physical immaturity or delays or mild cognitive pervasive developmental age appropriate or this there are concerns about disabilities. delays or profound cognitive information is unknown to possible delays and / or low disabilities. me. IQ. If the needs / functioning fall within a shaded box, explain why: child’s III-2. Cognitive Development (PAST 30 DAYS) Child’s Child shows no evidence of Child has some signs that Child has clear signs that Child has significant delays cognitive development cognitive skills are not development is not at the in cognitive functioning that problems. Any concerns are appropriate. Child may be expected level. Child may are seriously interfering with age appropriate or this unaware of surroundings, be unable to understand their functioning. Child is information is unknown to challenges in remembering simple routines or tasks. completely reliant on me. routines and completing caregiver to function. tasks such as sorting, recognizing colors. If the needs / functioning fall within a shaded box, explain why: child’s C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages Birth to 5) (Continued) III-3. Autism Spectrum (PAST 30 DAYS) development Evidence of mild symptoms Child has been diagnosed Severe autism. Symptoms Child’s appears normal in relation to of an autism spectrum by an appropriate are disabling in at least one autistic characteristics or disorder. Child may meet professional as having an area of life skills. this information is unknown criteria for Aspergers autism spectrum disorder. to me. disorder. If the needs / functioning fall within a shaded box, explain why: child’s
concerns are age appropriate or this information is unknown to me. Child is under the age of 3. include inappropriate comments to others or unusual behavior that results in sanctions to the child. that is causing problems in the child’s life. Child may be intentionally getting in trouble in school or at home. in serious and / or repeated sanctions to the child. If the child’s needs / functioning fall within a shaded box, explain why: C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages Birth to 5) III-1. Child’s Overall Development (PAST 30 DAYS) Child has no developmental problems. Any concerns are age appropriate or this information is unknown to me. Child has some problems with physical immaturity or there are concerns about possible delays and / or low IQ. Child has developmental delays or mild cognitive disabilities. Child has severe and pervasive developmental delays or profound cognitive disabilities. If the child’s needs / functioning fall within a shaded box, explain why: III-2. Child’s Cognitive Development (PAST 30 DAYS) Child shows no evidence of cognitive development problems. Any concerns are age appropriate or this information is unknown to me. Child has some signs that cognitive skills are not appropriate. Child may be unaware of surroundings, challenges in remembering routines and completing tasks such as sorting, recognizing colors. Child has clear signs that development is not at the expected level. Child may be unable to understand simple routines or tasks. Child has significant delays in cognitive functioning that are seriously interfering with their functioning. Child is completely reliant on caregiver to function. If the child’s needs / functioning fall within a shaded box, explain why: C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages Birth to 5) (Continued) III-3. Autism Spectrum (PAST 30 DAYS) Child’s development appears normal in relation to autistic characteristics or this information is unknown to me. Evidence of mild symptoms of an autism spectrum disorder. Child may meet criteria for Aspergers disorder. Child has been diagnosed by an appropriate professional as having an autism spectrum disorder. Severe autism. Symptoms are disabling in at least one area of life skills. If the child’s needs / functioning fall within a shaded box, explain why: