Dear Families, this checklist helps you share what you see and know about how your child is growing and learning. You know your child in a special way, and your ideas help us understand them better. When we work together, we can make the best plan to help your child. What you share really matters!
Social and Emotional Development
Have you seen or heard your child doing any of these things or acting in these ways?
- My child comforts themselves by holding a favorite toy or blanket.
- My child shares toys or takes turns during play with siblings or friends.
- My child shows excitement when greeting family members or visitors.
- My child expresses feelings (e.g., joy, frustration) through words or gestures.
Have you observed any of these behaviors? Yes ☐ No ☐
If yes, share details or similar examples:
_____________________________________________________________________________
Language and Literacy Development
Have you seen or heard your child doing any of these things or acting in these ways?
- My child asks questions like, "Why?" or "What's that?"
- My child enjoys being read to or looking at books independently.
- My child sings songs or repeats rhymes they know.
- My child uses words or phrases to describe objects or actions (e.g., "big car," "blue ball").
Have you observed any of these behaviors? Yes ☐ No ☐
If yes, share details or similar examples:
_____________________________________________________________________________
Cognitive and Problem-Solving Skills
Have you seen or heard your child doing any of these things or acting in these ways?
- My child works on puzzles or builds with blocks.
- My child sorts objects.
- My child pretends to cook, shop, or play other make-believe games.
- My child figures out how to open containers, turn on devices, or use tools.
Have you observed any of these behaviors? Yes ☐ No ☐
If yes, share details or similar examples:
_____________________________________________________________________________
Physical Development
Have you seen or heard your child doing any of these things or acting in these ways?
- My child runs, jumps, or climbs.
- My child threads beads or uses crayons to draw.
- My child feeds themselves.
- My child enjoys dancing or moving to music.
Have you observed any of these behaviors? Yes ☐ No ☐
If yes, share details or similar examples:
_____________________________________________________________________________
Self-Regulation and Emotional Growth
Have you seen or heard your child doing any of these things or acting in these ways?
- My child follows simple routines (e.g., bedtime, brushing teeth).
- My child waits patiently for their turn during family games or activities.
- My child uses words or gestures to ask for help or express frustration.
- My child calms down with a favorite activity, song, or breathing technique.
Have you observed any of these behaviors? Yes ☐ No ☐
If yes, share details or similar examples:
_____________________________________________________________________________
Additional Observations or Comments
Is there anything else you want to tell us about how your child is growing, what they like, or how they act?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Service Provider's Name: _________________________________________________
Contact Info: _________________________________________________
Thank you for sharing your valuable observations! If you have any questions or need assistance with this form, please reach out to us.
Together, we can support your child's growth and success!