M-CHAT English

Modified Checklist for Autism in Toddlers (M-CHAT)
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 answer yes or no for every question. Thank you very much.
INFORMED CONSENT

By providing your information, you consent to DePelchin Children’s Center collecting and maintaining your data in a secure database. The information in the developmental screeners are confidential and will be used for evaluation purposes only. The results of the screener(s) will only be shared with you to the email address and/or contact information you provide.
Signature*

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Date*

MonthDayYear
Date
Name of Child/Baby*

First NameLast Name
MaleFemale
Child's Date of Birth

MonthDayYear
Date
Caregiver Name*

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
YesNoNot sure
The developmental screener does not provide a diagnosis or identify children as having a developmental issue, but helps parents or caregivers determine if further evaluation by a doctor or other professional may be necessary. The results of the screener will be shared with you after you complete it. There is no cost to take the screener.

** MCHAT Screener should be used for children ages 16-30 months

** ASQ Screener should be used for children ages 1 month to 60 months. Use a screener that closely matches the child’s current age.
0- Yes1- No
1- Yes0- No
0- Yes1- No
0- Yes1- No
1- Yes0- No
0- Yes1- No
0- Yes1- No
0- Yes1- No
0- Yes1- No
0- Yes1- No
0- Yes1- No
1- Yes0- No
0- Yes1- No
0- Yes1- No
0- Yes1- No
0- Yes1- No
0- Yes1- No
0- Yes1- No
0- Yes1- No
0- Yes1- No
Total Score
Scoring

YES RESPONSES TO QUESTIONS 2, 5, 12 and NO RESPONSES TO ALL OTHER QUESTIONS indicates ASD risk.

ONE point for each item that indicates ASD risk.

LOW-RISK: Total Score is 0-2; if child is younger than 24 months, screen again after second birthday. No further action required unless surveillance indicates risk for ASD.

MEDIUM-RISK: Total Score is 3-7; Administer the Follow-Up (second stage of M-CHAT-R/F) to get additional information about at-risk responses. If M-CHAT-R/F score remains at 2 or higher, the child has screened positive. Action required: refer child for diagnostic evaluation and eligibility evaluation for early intervention. If score on Follow-Up is 0-1, child has screened negative. No further action required unless surveillance indicates risk for ASD. Child should be rescreened at future well-child visits.

HIGH-RISK: Total Score is 8-20; It is acceptable to bypass the Follow-Up and refer immediately for diagnostic evaluation and eligibility evaluation for early intervention.
For Help Me Grow Staff only:
Staff Name:
YesNo
ASQ ActivitiesCDC LTSAE materialsOther
Notes:
Should be Empty:

Modified Checklist for Autism in Toddlers (M-CHAT)

For Help Me Grow Staff only: