Parent Name *

First Name

Last Name

Phone *

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Does your child startle to loud sounds?

Yes

No

Not Sure

Does your child respond to changes in the tone of your voice?

Yes

No

Not Sure

Does your child make gurgling and raspberry sounds when alone or playing with you?

Yes

No

Not Sure

Does your child babble in a speech- like way and use many different sounds that begin with p, b, and m?

Yes

No

Not Sure

Does your child babble using long and short groups of sounds such as, "tata", "pups", and "bibi"?

Yes

No

Not Sure

Does your child understand words for common items such as "milk", "cup", and "shoe"?

Yes

No

Not Sure

Does your child respond to questions such as "come here"?

Yes

No

Not Sure

Does your child say one or two words such as "hello", "cup", "mama", or "dada"?

Yes

No

Not Sure