Intake Form Checklist – Age 4 months to 5 years Please find the corresponding section for your child’s age and check the corresponding boxes for skills that your child is regularly demonstrating. Name First Last 4 MonthsGross Motor Skills By 4 Months Bears weight on forearms when on belly. Plays with feet Holds head in midline Rolls from back to side Brings hands together when laying on back Fine Motor Skills By 4 Months Grasps rattle when placed in hand Reaches toward and touches toy Hits at dangling objects with hands Responds to a smile with a smile Like’s looking at a human face most Speech By 4 Months Sucks from breast or bottle Cooing: Vowel sounds Vocalizes some sounds Produces a variety of facial expression. 6 MonthsGross Motor Skills By 6 Months Sits a lone for short periods Begins to belly crawl Rolls back to belly and belly to back Grabs feet and brings them to mouth On belly props up on straight elbows Fine Motor Skills By 6 Months Reaches for a toy when playing on belly Holds a toy and shakes it Puts fingers in mouth Holds hands open at least 1/2 of the time Smiles at self in mirror Speech By 6 Months Cup drinking is introduced Soft, smooth solids Moves chewed food to center of mouth before swallowing 9 MonthsGross Motor Skills By 9 Months Maintains sitting for at least 60 seconds with hands free to play Crawls independently Pulls to stands from floor Walks with 2 hands held Fine Motor Skills By 9 Months Waves bye-bye Releases objects intentionally Feeds self finger foods Bangs a toy on the floor Passes a small object between hands Speech By 9 Months Babbles same sounds Responds to “no” Vocalizes different syllables Tolerates smooth solid foods Makes sounds while eating with food in mouth 12 Months (1 Year)Gross Motor Skills By 12 Months Cruises along furniture Independent standing Gets into and out of siting Corrals a ball with arms and hands in sitting Transitions sit to stand and stand to site Fine Motor Skills By 12 Months Grasp thick crayon or pencil in fist, does not mark Turns page of a cardboard book Helps to pull off simple clothing Puts objects into others Pulls shoes off Speech By 12 Months Feeding self with fingers Babbles using different sounds Takes turns vocalizing Points/gestures Tolerates coarsely chopped food 18 Months (1-1/2 Years)Gross Motor Skills By 18 Months Walks Independently with arms at side Walks up and down 3-4 steps with railing Walks backwards 5 steps Throws a ball while maintaining balance Rides a push bike Fine Motor Skills By 18 Months Turns a container to pour or dump contents Turns a small knob Gets spoon in mouth right-side up Helps to dress and undress self Puts large round pages into pegboard Speech By 18 Months Uses 10-20 words Combines 2 words (all done) Names at least 5 items Responds to “yes/no” Retrieves objects from another room when asked 24 Months (2 Years)Gross Motor Skills By 24 Months Stoops down to retrieve toy and returns to standing Jumps down off low surface Jumps forward about 4 inches Goes up stairs without rail (both feet on each step) Throws ball 3 feet in air Kicks ball 3 feet forward Fine Motor Skills By 24 Months Drinks from cup independently Looks independently at picture books Zips and unzips easy zippers Uses play dough, paint and paper Scribbles without going off paper Builds a 4-6 block tower Speech By 24 Months Frequently uses 2 word phrase Demonstrates verbal turn taking Has at least 100 words Eats table foods with mixed textures 30 Months (2-1/2 Years)Gross Motor Skills By 30 Months Stands on one foot for 3 seconds (hands on hips) Jumps forward 24 inches Jumps down 24 inches Catches a large ball Throws ball underhand Fine Motor Skills By 30 Months Washes hands by self Hand preference is established Imitates drawing a vertical line Puts square, round and triangular shapes into board Spontaneously draws strokes, dots and circles Stacks 7-8 small blocks Speech By 30 Months Gives first name Answers “where” questions Uses 3-4 word utterances Identifies object by function Responds to greetings Has approximately 450 words 36 Months (3 Years)Gross Motor Skills By 36 Months Walks up stairs without rail (one foot on each step) Rides a tricycle Hops 3 times on one foot Kicks a large ball in place Fine Motor Skills By 36 Months Grasps pencil with thumb and fingers instead of fist Screws and unscrews jar lids Eats with a fork (with spillage) Pours accurately from one container to another Completes a simple 3 piece puzzle Speech By 36 Months Has about 1000 words Converses in sentences Ask questions Responds to “wh-” questions Is 75% intelligible 4 Years (48 Months)Gross Motor Skills By 48 Months Stands on one foot for 5 seconds (hands on hips) Hops 5-8 times on each foot Rides a 2-wheeled bike with training wheels Walks backwards on a line over 4 feet Jumps forward 30 inches Fine Motor Skills By 48 Months Puts socks on correctly Colors almost entirely within lines of circle Draws a person with 3 different body parts Dresses and undresses without much help Copies a cross Speech By 48 Months Uses 4-5 word sentences Understands time concepts Uses contractions (don’t) Follows multi-step directions Asks many questions including “who” and “why” 5 Years (60 Months)Gross Motor Skills By 60 Months Completes sit ups Able to skip Completes jumping jacks Rides a 2-wheeler without training wheels Completes push-ups Fine Motor Skills By 60 Months Copies and cuts a square Copies color/shape sequence Zips most zippers Traces around own hand with crayon Completes simple dot to dot pictures Speech By 60 Months Uses a variety of sentences Vocabulary of 2000 words Can tell a story with plot is 90-100% intelligible Asks questions to get more information CANCELLATION FEE*In the event that my child receives more than one therapy service (speech, occupational, physical), I understand that each one follows an individualized plan of care specific to my child’s needs. It is important that they attend every scheduled appointment to address all areas of development needed to help my child improve. In the event that a clinician is out, resulting in one of the appointments to be cancelled, I understand that the office will do their best to reschedule with another clinician to help provide continuity of care. Should I decline to reschedule and/or cancel my child’s other appointments in such a situation, I understand that the attendance policy will be applied, and a no show/late cancellation fee may be assessed for each scheduled appointment that is not kept. Δ