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Developmental Questionnaire For 4-5 Year Olds

Dear Parents/Guardians,

In preparation for the 2026-2027 school year, it is the time of year where we begin the process of working with our partnered locations to offer screening and assessments. Please click here to learn more.

Fill Out The Form Below

"*" indicates required fields

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Child's Information

Child's Full Name*

First Middle Last

Gender*

Male

Female

Child's Date of Birth*

YYYY

MM

DD

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Age As Of August 31

Year

Month

Day

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Age In Years

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Age In Months

Name of Parent Completing Questionnaire*

First Last

Email*

Enter Email Confirm Email

Phone Number*

School / Program Information

Program Attending or Registered In*

Teacher (If Known)

Choose Days Child Attends*

Monday

Tuesday

Wednesday

Thursday

Friday

Start Time*

Hours

:

Minutes

AM/PM

End Time*

Hours

:

Minutes

AM/PM

Tell Us About Your Child

Children typically develop in a predictable sequence but at their own rate. Please check off all that apply. Does the child:*

Use words to tell you want they want, rather than gestures or whining?

Use 5-6 words in a sentence?

Say words clearly enough for unfamiliar adults to understand?

Engage in imaginary play with others?

Share with others?

Feel comfortable leaving you for short periods?

Recognize other people’s feelings?

Express their likes and dislikes through words?

Take turns with others?

Follow simple 3 step verbal directions?

Put most clothes on by him/herself?

Use the washroom (with help)?

Walk up/downstairs unaided?

Walk, run, climb, ride a tricycle or bicycle with training wheels?

Catch a large ball thrown from 5 or 6 feet away?

Name colors?

Count in order to 5?

Name some letters?

Recite or sing the alphabet? (May not yet know the names of many letters or the sounds they make)

Tell stories about recent events?

Feed him/herself?

Hold a crayon or marker?

Copy simple shapes like circles?

Cut along a line with scissors?

Enjoy stories and books?

Have any medical issues or diagnoses?

Please explain the Childs medical issues or diagnoses

Please tell us if you have any concerns about the child’s development

Speech/language (following directions, not speaking, unable to communicate their wants/needs etc); fine motor skills (like picking things up, holding a pencil etc); large motor skills (like jumping, running, balancing etc); concerning behaviour; big emotions; anxiety; play skills; sensory challenges (do they have trouble calming when upset, do they avoid messy play etc).

Please tell us about the child’s strengths, interests – what excites them?*

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