Is your child able to easily transition between Is your child motivated to interact with peers? activities and environments? Yes Yes No No Please comment on your child’s pretend play Does your child exhibit skills (e.g., combing doll’s hair, pushing train behaviors? on tracks, etc.): Yes No If yes, please describe: If Yes, is he/she currently receiving behavioral intervention? Yes No If yes, please describe: Communication Does your child currently: (Check all that apply) Understand simple directions? Example: ______________________________________ Understand names for people and objects? Understand names for body parts? Answer simple questions? Example: __________________________________________ Understand prepositions (in, under, on)? Understand color and size words? Which of the following describe(s) how your child communicates? (Check all that apply) Points, gestures, vocalizes Speaks single words
Is your child able to easily transition between activities and environments? Yes No Is your child motivated to interact with peers? Yes No Please comment on your child’s pretend play skills (e.g., combing doll’s hair, pushing train on tracks, etc.): Does your child exhibit behaviors? Yes No If yes, please describe: If Yes, is he/she currently receiving behavioral intervention? Yes No If yes, please describe: Communication Does your child currently: (Check all that apply) Understand simple directions? Example: ______________________________________ Understand names for people and objects? Understand names for body parts? Answer simple questions? Example: __________________________________________ Understand prepositions (in, under, on)? Understand color and size words? Which of the following describe(s) how your child communicates? (Check all that apply) Points, gestures, vocalizes Speaks single words
iCan_Communicate_Pediatric_Intake_Form_March_2013.docx