EI Program Intake Questionnaire – 3 Years Old

Does your child engage in pretend play and use toys appropriately? *

Does your child ask for an item by name? *

Does your child say at least 50 words? *

Does your child answer simple questions; such as "yes/no" and "what"? *

Does your child understand language concepts (big/little, hot/cold)? *

Does your child speak in 2 to 3 word phases? *

Do people other than family members understand some of what your child says? *

Does your child point to named objects in pictures and books? *

Can your child hold a crayon with a basic grasp? *

Can your child copy a vertical line and circle when given a model? *

Can your child stack a few blocks? *

Can your child pick up a raisin or cheerio with the thumb and first finger only? *

Can your child walk without adult support? *

Can your child run without falling? *

Can your child walk up at least 4 stairs without support? *

Can your child catch a ball when gently tossed to him/her? *

Can your child kick a ball forward 1-2 feet? *

Can your child jump upward/forward and jump down from a step? *

Can your child stand on one foot for 2 seconds? *

Can your child throw a ball at least 5-6 inches? *

Does your child sit, listen, or play independently for at least 3 minutes? *

Does your child take turns with assistance? *

Does your child initiate social contact with peers during play? *

Can your child match at least 4 colors? *

Does your child match a circle, square, and triangle? *

Does your child count to at least 3? *

Does your child follow a 1 step direction that is not part of a daily routine? *

Does your child sit and rock self? *

Does your child seem to be constantly moving in some way? *

Does your child overreact to common sounds or cover his/her ears a lot? *

Does your child consistently avoid certain food textures, such as crunchy (rice krispies) or smooth (pudding)? This question is just for texture not taste. *

Is your child's behavior a concern to you? *

Are there any other concerns that you have for your child? *