M-CHAT-R
Parent / Guardian Name
*
First Name
Last Name
Parent / Guardian Email
*
example@example.com
Parent / Guardian Phone number
*
Please enter a valid phone number.
Child's Name
*
First Name
Last Name
Child's Date of Birth
-
Month
-
Day
Year
Date Picker Icon
Calculation
Child's Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
What is your relationship to the child
Please Select
Parent/Caregiver
Teacher/Educator
Referral Provider
Other
Closest Kind Behavioral Health clinic location
*
Please Select
Asheville
Charlotte - Concord
Charlotte - Huntersville
Charlotte - Midtown
Charlotte - Pineville
Charlotte - Matthews
Triangle - Northeast Raleigh
Triangle - Southeast Raleigh
Triangle - Holly Springs
Triangle - Research Triangle Park
Triangle-Durham
Triad - Winston - Salem
Triad - Greensboro
Wilmington
Greenville
McAdenville
Georgia-Savannah
Fayetteville - Walter Reed
West Fayetteville - Williamwood
How did you hear about KBH?
Please Select
Online Search
Facebook
Instagram
Medical provider referral
Insurance provider referral
Teacher/School
Current or past Kind Behavioral Health family
Community Presentation
Billboard/Sign
Brochure
Other
Please select your City and State
M-CHAT-R
Please answer these questions about your child. Keep in mind how your child usually behaves. If you have seen your child do the behavior a few times, but he or she does not usually do it, then please answer no. Please select yes or no for every question. Thank you very much.
1. If you point at something across the room, does your child look at it? (FOR EXAMPLE, if you point at a toy or an animal, does your child look at the toy or animal?)
*
Yes
No
2. Have you ever wondered if your child might be deaf?
*
Yes
No
3. Does your child play pretend or make-believe? (FOR EXAMPLE, pretend to drink from an empty cup, pretend to talk on a phone, or pretend to feed a doll or stuffed animal?)
*
Yes
No
4. Does your child like climbing on things? (FOR EXAMPLE, furniture, playground equipment, or stairs)
*
Yes
No
5. Does your child make unusual finger movements near his or her eyes? (FOR EXAMPLE, does your child wiggle his or her fingers close to his or her eyes?)
*
Yes
No
6. Does your child point with one finger to ask for something or to get help? (FOR EXAMPLE, pointing to a snack or toy that is out of reach)
*
Yes
No
7. Does your child point with one finger to show you something interesting? (FOR EXAMPLE, pointing to an airplane in the sky or a big truck in the road)
*
Yes
No
8. Is your child interested in other children? (FOR EXAMPLE, does your child watch other children, smile at them, or go to them?
*
Yes
No
9. Does your child show you things by bringing them to you or holding them up for you to see – not to get help, but just to share? (FOR EXAMPLE, showing you a flower, a stuffed animal, or a toy truck)?
*
Yes
No
10. Does your child respond when you call his or her name? (FOR EXAMPLE, does he or she look up, talk or babble, or stop what he or she is doing when you call his or her name?)
*
Yes
No
11. When you smile at your child, does he or she smile back at you?
*
Yes
No
12. Does your child get upset by everyday noises? (FOR EXAMPLE, does your child scream or cry to noise such as a vacuum cleaner or loud music?)
*
Yes
No
13. Does your child walk?
*
Yes
No
14. Does your child look you in the eye when you are talking to him or her, playing with him or her, or dressing him or her?
*
Yes
No
15. Does your child try to copy what you do? (FOR EXAMPLE, wave bye-bye, clap, or make a funny noise when you do)
*
Yes
No
16. If you turn your head to look at something, does your child look around to see what you are looking at?
*
Yes
No
17. Does your child try to get you to watch him or her? (FOR EXAMPLE, does your child look at you for praise, or say “look” or “watch me”?)
*
Yes
No
18. Does your child understand when you tell him or her to do something? FOR EXAMPLE, if you don’t point, can your child understand “put the book on the chair" or "bring me the blanket"?)
*
Yes
No
19. If something new happens, does your child look at your face to see how you feel about it?(FOR EXAMPLE, if he or she hears a strange or funny noise, or sees a new toy, will he or she look at your face?)
*
Yes
No
20. Does your child like movement activities? (FOR EXAMPLE, being swung or bounced on your knee)
*
Yes
No
Status
Date
-
Month
-
Day
Year
Date
Age
Submit
© 2009 Diana Robins, Deborah Fein, & Marianne Barton
Should be Empty: