Akila's response to Toronto Speech Dev Referral

By 2 years

Page 1: 

Follow two-step directions (Go find your teddy bear and show it to Grandma)(Y/N) ? 
<July 20th 2015 Akila Response> 
Use 100 to 150 words (Y/N) ?
<July 20th 2015 Akila Response> 
Use atleast two pronouns (you, me, mine) (Y/N) ?  
<July 20th 2015 Akila Response> 
Consistently combine two to four words in short phrase (Daddy hat.Truck go down) (Y/N)  
<July 20th 2015 Akila Response> 
Enjoy being around other children (Y/N) ?
<July 20th 2015 Akila Response> 
Begin to offer toys to other children and imitate other children's actions and words (Y/N)? 
<July 20th 2015 Akila Response> 
Use words that are understood by others 50 to 60 per cent of the time (Y/N)? 
<July 20th 2015 Akila Response> 
Form words or sounds easily and without efforts  (Y/N)?
<July 20th 2015 Akila Response> 
Hold books the right way up and turn the pages (Y/N)? 
<July 20th 2015 Akila Response> 
Read to stuffed animals or toys  (Y/N)?
<July 20th 2015 Akila Response> 
Scribble with crayons (Y/N)? 
<July 20th 2015 Akila Response> 
Do you have any other speech and language concerns for your child (Y/N)? 
<July 20th 2015 Akila Response> 

Page 2: Your Child's Communication

Do others understand your child                                                         Yes/No/Not Sure
<July 20th 2015 Akila Response>
Do you think your child stutters                                                         Yes/No/Not Sure
<July 20th 2015 Akila Response>
Does your child usually look at you when you talk to him/her              Yes/No/Not Sure
<July 20th 2015 Akila Response>
Does your child like to play with lots of different toys                         Yes/No/Not Sure
(not the same toy over and over again) ?           
<July 20th 2015 Akila Response>
Has your child lost any language or social skills                                  Yes/No/Not Sure
<July 20th 2015 Akila Response>
Does your child enjoy playing with other children                              Yes/No/Not Sure 
<July 20th 2015 Akila Response>
Has a professional spoken to you about your child's speech                 Yes/No/Not Sure
and language?  
<July 20th 2015 Akila Response>                                  
if yes, please describe                                                                                     Yes/No/Not Sure

Page 3 is a referral consent for personal info

Page 4 Parent or Guardian Information

Page 5 Child info incl DOB

Page 6 Your Child's Daily program 

       Name of the daycare program if any

Page 7 Your Child's Hearing and Vision

Do you have any concerns about your child's hearing?                              Yes/No
Has your child had three or more ear infections in the past year?             Yes/No
Was your child's hearing tested at birth                                                   Yes/No
if yes, when and what were the results? Please include any future hearing test dates 
do you have any concern about child's vision ?                                          Yes/No
Has your child's vision been tested?                                                          Yes/No
Has your child's vision been tested? 
if yes, when and what were the results? Please include any future vision test dates

Page 8 Your Child's Growth and Development

Do you have any concerns with your child's feeding and eating habits, or chewing and swallowing?   Yes/No 

if yes, describe