Forms • Lucas County • CivicEngage

Child's Name*

Child's date of birth*

Diagnosis, if any

Full term/Preemie (how many weeks)*

Parent(s) name*

Phone

Email

Zip Code

Today's Date*

Check the box next to the skills your child has mastered.

	Stand on one foot for 10 seconds or longer.
	Hops.
	Walks Attempts a somersault.
	Independently uses a swing. ball.
	Climbs on/over playground equipment independently.
	May be able to skip.
	Copies triangle and other geometric patterns.
	Draws a person with a body.
	Prints most capital letters.
	Dresses and undresses independently.
	Recalls at least 3 parts of a story.
	Speaks in 5-6 word sentences.
	Uses future tense when talking.

	Can tell a longer story with a beginning and ending.
	Can state name and address.
	Can count ten or more objects.
	Correctly names at least four colors.
	Can work in a small group for 5-10 minutes.
	Understands the concept of short amount of time.
	Knows about things used everyday in the home (money, food, etc.).
	Uses a spoon and fork independently.
	Can chew food with lips closed.
	Goes to the bathroom independently (may need a reminder).
	Prefers to play with friends.
	More likely to agree to the rules of a simple game.
	Likes to sing, dance and act.

Please contact me for follow up:*

Regardless if there is a concern or not

Only if there is a concern.

The best way to reach me is

By phone (listed above)

By email (listed above)

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