LEAF Parent Questionnaire

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Email *

Parent's name and contact number:

Child's first name?

Child's date of birth:

How does your child currently interact with other children?

Prefers to play alone

Tolerates playing next to other children

Will play when approached by a peer

Initiates play with others

Sustains play for 2 or more minutes

Other:

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How does your child interact with toys?

Consistently throws toys

Consistently bangs toys together or on a surface

Lines toys up

Consistently dumps toys

Consistently plays with toys in the manner for which they were designed

Other:

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Your child appropriately...

Always

Often

Sometimes

Never or almost never

Responds to name when called

Follows directions with a gestural cue (e.g., "Bring me the book" while pointing to the book)

Follows directions without a gestural cue (e.g., "Bring me the book")

Stops a behavior, such as tapping a foot, when asked

Tells details of an experience or story in the order they occurred

Gives hugs or offers other expressions of affection

Demonstrates turn-taking rules during play for a minimum of 2 turns at a time

Maintains attention while another person speaks

Engages in symbolic play (e.g., using a block as a phone, crayon as a microphone)

Greets others (i.e., waves or says hello/goodbye)

Always

Often

Sometimes

Never or almost never

Responds to name when called

Follows directions with a gestural cue (e.g., "Bring me the book" while pointing to the book)

Follows directions without a gestural cue (e.g., "Bring me the book")

Stops a behavior, such as tapping a foot, when asked

Tells details of an experience or story in the order they occurred

Gives hugs or offers other expressions of affection

Demonstrates turn-taking rules during play for a minimum of 2 turns at a time

Maintains attention while another person speaks

Engages in symbolic play (e.g., using a block as a phone, crayon as a microphone)

Greets others (i.e., waves or says hello/goodbye)

Clear selection

Your child is affected by...

Always affected

Often affected

Sometimes affected

Never or almost never affected

Change in routine

Loud noises

Play being inturrupted

Senosry adversions (being wet, touching certain textures)

What are your child's strengths and interests?

Additional information you would like us to know...

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