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  • Happy Talkers Early Screenings

  • We want your child's screening experience to be as enjoyable and effective as possible! Please complete the following form to the best of your ability. Getting to understand your child and your concerns in advance will help our team best serve your needs.

    If you have difficulty answering any sections, a Happy Talkers volunteer will help you at the Screening Event.

    We look forward to meeting you and your child!

  • Child's Gender*
  • Format: 0000-00000.
  • Please check specific areas of concern for your child*
  • Has your child had a hearing test?*

  • At what age did your child...

    Please answer the following questions using your child's age in MONTHS when they first performed the task listed. If they've not yet reached that benchmark, plesae enter "N/A".

  • Ages & Stages Questionnaires: Social-Emotional

  • Does your child look at you when you talk to him?
  • Does your child cling to you more than you expect?
  • Does your child talk and/or play with adults she knows well?
  • When upset, can your child calm down within 15 minutes?
  • Does your child like to be hugged or cuddled?
  • Does your child seem too friendly with strangers?
  • Can your child settle himself down after periods of exciting activity?
  • Does your child cry, scream, or have tantrums for long periods of time?
  • Is your child interested in things around her, such as people, toys, and foods?
  • Does your child stay dry during the day?
  • Does your child have eating problems, such as stuffing foods, vomiting, eating nonfood items, or _______________________ ? (You may write in another problem below.)
  • Do you and your child enjoy mealtimes together?
  • Does your child do what you ask her to do?
  • Does your child seem happy?
  • Does your child sleep at least 8 hours in a 24-hour period?
  • Does your child seem more active than other children his age?
  • Does your child use words to tell you what she wants or needs?
  • Does your child stay with activities he enjoys for at least 10 minutes (not including watching television)?
  • Does your child use words to describe her feelings and the feelings of others, such as, “I’m happy,” “I don’t like that,” or “She’s sad”?
  • Does your child move from one activity to the next with little difficulty, such as from playtime to mealtime?
  • Does your child explore new places, such as a park or a friend’s home?
  • Does your child do things over and over and can’t seem to stop? Examples are rocking, hand flapping, spinning, or _______________________ . (You may write in another problem below.)
  • Type a question
  • Does your child follow rules (at home, at child care)?
  • Does your child destroy or damage things on purpose?
  • Does your child stay away from dangerous things, such as fire and moving cars?
  • Can your child name a friend?
  • Does your child show concern for other people’s feelings? For example, does she look sad when someone is hurt?
  • Do other children like to play with your child?
  • Does your child like to play with other children?
  • Does your child try to hurt other children, adults, or animals (for example, by kicking or biting)?
  • Does your child show an interest or knowledge of sexual language and activity?
  • Has anyone expressed concerns about your child’s behaviors? If you checked “sometimes” or “most of the time,” please explain below.

  • ASQ: SE, Squires et al. (c) 2002 Paul H. Brooks Publishing

  • By clicking "Submit", you agree to the following:

    The Happy Talkers Foundation for Autism "developmental screenings" are an aid to identify if your child is at risk for a developmental delay such as autism.  It may help identify behaviors that could suggest a child has autism but it is not a conclusive diagnostic tool nor is it a treatment for autism. Parents are strongly recommended to use independent judgment and to seek other resources when considering any opinions associated with a diagnosis or treatment and services related to autism and developmental delays. 

    Our recommendations and resource materials are meant to assist you in achieving a greater understanding of your child’s health and provide an overview of management strategies.  We do not discuss unproven practices, make any diagnosis, or recommend any particular treatment option.  We do not represent pharmaceutical interests and have not received funding from such organizations.  

    Neither Happy Talkers Foundation for Autism, or the sponsors and entities involved in the screening events, endorse, warrant or otherwise support the comments, opinions or other statements made by any service provider at or through the Happy Talkers Foundation for Autism screening. Each service provider is an independent contractor. These entities are not liable for any direct, indirect, punitive, incidental, special, consequential or other damages arising out of or in any way connected with the use of the service providers or with the delay or inability to use the service or otherwise arising out of the use of the service, whether based on contract, tort, strict liability or otherwise, even if advised of the possibility of damages.

    Happy Talkers Foundation for Autism is a not-for-profit, public benefit organization and information and support obtained from us is intended to expedite early intervention and provide a roadmap for your child’s development.  It is not a replacement for a formal evaluation.

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