M-CHAT-R/F RESULT

Date: [Date]
Child: [Name or ID, date of birth]
Age in months: [Age on the day of screening; valid from 16 to 30 months]
Visit: [18-month visit, 24-month visit, rescreen, or a concern raised by the family or clinician]
Screened by: [Name, credentials]

SCREEN
Completed by: [Parent or caregiver and relationship; on paper, on a tablet, online, or read aloud]
Language: [Language of the form; official translation or interpreter used]
Total: [0 to 20, the number of at-risk answers]
Risk level: [Low 0 to 2, medium 3 to 7, or high 8 to 20]
At-risk questions: [Question numbers answered at risk]

FOLLOW-UP INTERVIEW
Done: [Yes, with whom, in person or by phone, and the date; or not needed because the total was low or high]
Follow-Up score: [Number of questions still at risk after the interview; 2 or more is positive]
In the parent's words: [Short examples of what the child does at home]

RESULT
Screen: [Negative or positive]
Other concerns: [Family worries, lost words or skills, red flags seen today, hearing history; or none]
Decision: [Routine rescreen, closer watch at each visit, or refer]

REFERRALS
Diagnostic evaluation: [Service and date sent, or not needed]
Early intervention: [Program and date sent, or not needed]
Audiology: [Hearing test and date booked, or not needed]
Speech-language: [Speech-language pathology and date sent, or not needed]
Results shared with: [Who receives the screening results, with the family's agreement]

EXPLAINED TO THE FAMILY
What the result means: [A screen, not a diagnosis; what happens next]
Their questions: [What the family asked, and the answers given]
Written information: [Handout or link, and its language; or none]

NEXT STEPS
Rescreen: [Date or visit, such as the 24-month visit; or not needed]
Referral check: [Who confirms the referrals arrived, and by when]
Return sooner if: [Lost words or skills, new worries from the family]

Signed: [Name, credentials, date]