Chie rat mame: hits gender: Crile GPrenae First name: VC tunname: (ici mbra. ‘Other ramber Or Oo ‘Age st acniristration inmonthe nd day ile 1D Program 0 € 201480000 ‘aes & Stages Ourtennsie® Sci neti soto S096 2,‘Questions about behaviors cidron may have are listed onthe following pages Please read each question carefully and check the box [if that best sures your chids behavior Aso, chek the cicle @ the behaviors 3 concer Important Points to Remember: [Answer questions based on what you know about your) Please return this questionnaire by: ______—— chids behavior 1D yeu have any questions o concerns about yout cid or . Aswer question baved on your chiles use! behavior, bout this querormave, contact tot behavior when you cide sck, very ted, or unary.) Thankyou and please lock forward 0 fiing ot anather 1 Caregivers who know the child well and spend more than ASCLSE-2in monte. 15-20 hours per week with the cid should complete ASOSE-2, 1 2 Does your child look at you when you talk to him? Does your child cing to you more than you expect? le ‘Does your child talk or play with adults she knows well? lo When upset, can your child calm down within 15 minutes? lo ‘Does your childlike to be hugged or cuddled? Co Does your child seem too friendly with strangers? Does your child settle himself down after exciting activities? Does your child ery, scream, or have tantrums for long periods of time? 201480100 Sit ali tock Ping a, re Argh red TOTAL POINTS ON PAGE ges Sees Quetcrrles® Sxl Enea Scand Eton ASCSE2™, Sac, Bich, K Twombly ° ilg lo le48 Month Questionnaire Check the box that best describes your cis bebavice Alto, check the Ecle @ fhe behave is concer 10. 1" 12. 13, 14, 15. 16, 17, 18. 19. 's your child interested in things around her, suchas people, toys, and foods? Does your child stay dry during the day? Does your child have eating problems? For example, does he. stuff food, vomit, eat things that are not food, or (Please describe.) ee ie Pe ee ant 1 A aes, Bo you and your child enjoy mealtimes together? Does your child co what you ask her to do? Does your child seem happy? Does your child sleep atleast & hours ina 24-hour period? Does your child seem more active than other children his age? Does your child use word to tell you what she wants or needs? Does your child stay with activities he enjoys for at least 10 minutes (other than watching shows or videos, or pleying with electronics)? Does your child use words to describe her feelings and the feelings of others? For example, does she say, “I'm happy,” "don't like that," or “She's sad?” e Ob IC eR lo lo Q k Os R +P201480200 ora rons on ruse O). ‘Ae 8 Sages Questions Sac Emon cond Edition ASOSE2™, Sq Bia &Taonbh. nats ‘CainS Psi teste hbishng Cae Ags reence48 month Questionnaire a 2 2. 2m. 28, 2. Does your child move from one activity to the next with tle difficulty for example, from playtime to mealtime)? Does your child explore new places, such as a pak or a friend's home? Does your child do things over and over and get upset when you try to stop him? For example, does he rock, flap his hands, spin, or __? lease describe.) oes your child hurt herself on purpose? Does your child follow rules at home or st child care? Does your child destroy or damage things on purpose? Does your child stay away from dangerous things, such as fre and moving cars? Can your child name a friend? Does your child show concem for other people's feelings? For example, does he Ch ‘ae look sad when someone is hurt? Do other children lke to play with your child? oO O 201480300 rosronns onmace O ‘or 8 Sgn Quon Si Eman Ser Elo ASOSEZ™) Sis, hs 8 Ton "© 2015 Poul H. Brockes Publishing Co., Inc.All nights reserved. ~ pope dotseck ie bor [that bet deseites your chs behavior Ato check the ele & tether a concern i owner 48 month Questionnaire = 30. Does your chit to ply ih ther hen? oO a 31. oes ou cil yt hart ter in, du, or nial for orl! ‘example, by kicking or biting)? <3 ry) 32. Does your child show an unusual interest in or knowledge of sexual language and activity? 33. Dees your child wake three or more times during the night? 34. Is your child too worried or fearful? If “sometimes” or “often or always,” please describe: 35. Does your child have simple back-and-forth conversations with you? For example, Parent: “It's raining!” Child: “And cold outside.” Parent: "Let's get your cost.” i Child: “I got it” 36, Has anyone shared concemns about your child's behaviors? Hf “sometimes” or “often or always,” please expla ToraLrontsourace Stges Ovo sre Sand Eston (ASC SE2™, Sits, Bch, womb 201480400 fee Stats acl boss Rin Conbe Alogi esse prvedels48 month Questionnaire OVERALL Use the sce below for atonal comments 37. Doyou have concerns about your childs eating, sleeping, o toileting habits? ity, please explain: Ow Gr 38, Does anything about your child worry you? if yes, please explain: Ow Gr 39. What do you enjoy about your child? i er t omile, enemies Ondk Nositive Z, 4, f Arm ng 4 sings Qvestonsies® Sac Ect Second Eten ASOSE2™, Sau, Bich, B Twombly 201480500 ne apa toes Pbioang Co, re Arges sane BalslisChild's nam Date ASO:SE.2 completed: caer Chace i a chai acd nd Be Administering progrem/provider: Chile's gender: OMale G)Female Be wis en ee ‘Reeve uatcomneneaecee [wanes | cote hid tol aor nent he ca s |O SOT Saal) 2. BSOLSE:2 SCORE INTERPRETATION: Review the appronimate location of he childs total seve onthe scoring graphic. Then, check off the area for the score results below. “The chit total scorisin the ra, below he ctl. Scis-emotional development appears tobe on schedule — The chiles total sora isin the tres. tis close tothe cute Review behovirs of concem sed nomen — The cles total scores inthe mm area. Its sbove the cutof. Further assessment wth» professionel me be needed. 1-86. Any Concerns marked on scored items? YES Comments: = 37. Eating/sleepingitolleting concerns? YES (nd) Comments 38. Other worries? YES (8) commen “-FRIFOMUP REFERRAL CONSIDERATIONS: Mark al as Ys, Noor Unsure (YN, Ul. See pages 98-13 inthe ASCSE? User’ Gute —* Setting/time factors (e.g, ls the child's behavior the same at home as at school?) 1M. Developmental factors (el the child's behavior reloted to a developmental stage or dela?) LAL Health factors (e.g, 1s the cits behavior related to health or biological factors?) -LN Fantyfetturl factors the cits behavior acceptable given the chs ehurl or family contest? Have there been any stressful events in the childs Ife recently?) Parent concerns (e.g, Did the parent/caregiver express any concems about the cil’s behavior?) 5, FOLLOW-UP ACTION: Check all that apply. — Provide activities and rescreen in months. — Share results with primary heath care provider. —— Provide parent education materials. — Provide information about available parenting classes or support groups. — lise another caregiver complete ASO:SE-2. Uist caregverhere(.g, grandparent, teacher "Administer developmental screening (.9., ASQ-3). — Ree to earl intervention/eatly childhood special education, — Reterfor social-emotional, behavioral, or mental heath evaluation, Other: 201480600 ‘ge Sings Gre Seon Eston ASOSE 20) Saute, rk Boeri "Sia pat ener tg ee AS 20 a