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.

	Hops and stands on one foot up to 5 seconds.
	Goes upstairs and downstairs without support.
	Kicks a ball forward.
	Throws a ball overhand.
	Catches a bounced ball most of the time.
	Pedals tricycle.
	Copies square shapes.
	Draws a person with 2-4 body parts.
	Uses scissors.
	Draws circle and squares.
	Begins to copy some capital letters.
	understands the concept of same and different.
	Speaks in sentences 5-6 words long.
	Uses pronouns (I, you, me, we, they).
	Asks questions.
	Speaks clearly enough for strangers to understand.
	Tells stories to adults.
	Correctly names 2-3 colors.
	Understands the concept of counting and may know a few numbers.

	Begins to have clearer sense of time.
	Follows three part commands.
	Recalls facts from a simple story.
	Engages in pretend activities.
	Knows that they cause things to happen.
	Can feed self with a spoon without spilling.
	Washes/dries hand and face.
	Can do simple household chores such as set the table.
	Can put simple clothing on with help for buttons, zippers and shoelaces.
	Can brush or comb through own hair.
	Interested in new experiences.
	Cooperates/plays with other childrlen
	Plays 'mom' and 'dad.'
	Can stay on topic during a conversation.
	More independent.
	Plays simple games with simple rules.
	Begins to share toys.
	Often cannot distinguish between pretend and reality.
	May have imaginary friends or see monsters.

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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