(For infants ages 15 through 18 months)
Please provide the following information.
Please read each question carefully and
1. Check the box that best describes your child's behavior and
2. Check the circle if this behavior is a concern.
Z (for zero) next to the check box = 0 points
V (for Roman Numeral V) next to the check box = 5 points
X (for Roman Numeral X) next to the check box = 10 points
Checked concern = 5 points
1. Review Questionnaires
Review the parent's answers to questions. Give special consideration to any individual questions that score 10 to 15 points or any written or verbal comments that the parent shares. Offer guidance, support, and information to families, and refer if necessary, as indicated by score and referral considerations.
2. Transfer child's total score.
In the table below, enter the child's total score (transfer total score from above).
3. Referral Criteria
Compare the child's score with the cutoff in the table above. If the child's score fall about the cutoff and the factors in Step 4 have been considered, refer the child for a mental health evaluation.
4. Referral considerations
It is always important to look for assessment information in the context of other factors influencing a child's life. Consider the following variables prior to making referrals for a mental health evaluation. Refer to pages 44-46 in The ASQ:SE User's Guide for additional guidance related to these factors and for suggestions for follow-up.
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