{"id":3833,"date":"2020-10-21T18:12:43","date_gmt":"2020-10-21T22:12:43","guid":{"rendered":"https:\/\/youngmindsinmotion.com\/?page_id=3833"},"modified":"2020-10-21T19:52:41","modified_gmt":"2020-10-21T23:52:41","slug":"54-month-assessment","status":"publish","type":"page","link":"https:\/\/youngmindsinmotion.com\/es\/54-month-assessment\/","title":{"rendered":"Evaluaci\u00f3n de 54 meses"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3833\" class=\"elementor elementor-3833\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-c361ace elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"c361ace\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-44525dd\" data-id=\"44525dd\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-ad2b305 elementor-widget elementor-widget-wp-widget-gform_widget\" data-id=\"ad2b305\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wp-widget-gform_widget.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<link rel='stylesheet' id='gforms_reset_css-css' href='https:\/\/youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/legacy\/css\/formreset.min.css?ver=2.9.31' type='text\/css' media='all' \/>\n<link rel='stylesheet' id='gforms_datepicker_css-css' href='https:\/\/youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/legacy\/css\/datepicker.min.css?ver=2.9.31' type='text\/css' media='all' \/>\n<link rel='stylesheet' id='gforms_formsmain_css-css' href='https:\/\/youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/legacy\/css\/formsmain.min.css?ver=2.9.31' type='text\/css' media='all' \/>\n<link rel='stylesheet' id='gforms_ready_class_css-css' href='https:\/\/youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/legacy\/css\/readyclass.min.css?ver=2.9.31' type='text\/css' media='all' \/>\n<link rel='stylesheet' id='gforms_browsers_css-css' href='https:\/\/youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/legacy\/css\/browsers.min.css?ver=2.9.31' type='text\/css' media='all' \/>\n<script type=\"text\/javascript\" src=\"https:\/\/youngmindsinmotion.com\/wp-includes\/js\/dist\/dom-ready.min.js?ver=f77871ff7694fffea381\" id=\"wp-dom-ready-js\"><\/script>\n<script type=\"text\/javascript\" src=\"https:\/\/youngmindsinmotion.com\/wp-includes\/js\/dist\/hooks.min.js?ver=4d63a3d491d11ffd8ac6\" id=\"wp-hooks-js\"><\/script>\n<script type=\"text\/javascript\" src=\"https:\/\/youngmindsinmotion.com\/wp-includes\/js\/dist\/i18n.min.js?ver=5e580eb46a90c2b997e6\" id=\"wp-i18n-js\"><\/script>\n<script type=\"text\/javascript\" id=\"wp-i18n-js-after\">\n\/* <![CDATA[ *\/\nwp.i18n.setLocaleData( { 'text direction\\u0004ltr': [ 'ltr' ] } );\n\/* ]]> *\/\n<\/script>\n<script type=\"text\/javascript\" id=\"wp-a11y-js-translations\">\n\/* <![CDATA[ *\/\n( function( domain, translations ) {\n\tvar localeData = translations.locale_data[ domain ] || translations.locale_data.messages;\n\tlocaleData[\"\"].domain = domain;\n\twp.i18n.setLocaleData( localeData, domain );\n} )( \"default\", {\"translation-revision-date\":\"2026-03-27 23:59:20+0000\",\"generator\":\"GlotPress\\\/4.0.3\",\"domain\":\"messages\",\"locale_data\":{\"messages\":{\"\":{\"domain\":\"messages\",\"plural-forms\":\"nplurals=2; 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El contenido incluye el enlace para volver y completar el formulario.\"}};\n\/* ]]> *\/\n<\/script>\n<script type=\"text\/javascript\" defer='defer' src=\"https:\/\/youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/js\/gravityforms.min.js?ver=2.9.31\" id=\"gform_gravityforms-js\"><\/script>\n<script type=\"text\/javascript\" src=\"https:\/\/youngmindsinmotion.com\/wp-includes\/js\/jquery\/ui\/core.min.js?ver=1.13.3\" id=\"jquery-ui-core-js\"><\/script>\n<script type=\"text\/javascript\" src=\"https:\/\/youngmindsinmotion.com\/wp-includes\/js\/jquery\/ui\/datepicker.min.js?ver=1.13.3\" id=\"jquery-ui-datepicker-js\"><\/script>\n<script type=\"text\/javascript\" defer='defer' src=\"https:\/\/youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/js\/datepicker-legacy.min.js?ver=2.9.31\" id=\"gform_datepicker_legacy-js\"><\/script>\n<script type=\"text\/javascript\" defer='defer' src=\"https:\/\/youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/js\/datepicker.min.js?ver=2.9.31\" id=\"gform_datepicker_init-js\"><\/script>\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_24' ><form method='post' enctype='multipart\/form-data'  id='gform_24'  action='\/es\/wp-json\/wp\/v2\/pages\/3833' data-formid='24' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_24' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_24_1\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/www.youngmindsinmotion.com\/wp-content\/uploads\/2016\/09\/YMIM-logo-2.png\" width=\"247\" height=\"90\" \/ style=\" display: block; margin-left: auto;\n  margin-right: auto;\">\n<h2 style=\"text-align:center;\">PARENT QUESTIONNAIRE\n<\/h2>\n<\/li><li id=\"field_24_2\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p class=\"p1\"><span class=\"s1\">Dear Parents,<\/span><\/p>\n<p class=\"p3\"><span class=\"s1\">Please help us get to know your child <\/span><span class=\"s2\">by <\/span><span class=\"s1\">filling out this form. <\/span><span class=\"s3\">All <\/span><span class=\"s1\">the information will be confidential. We <\/span><span class=\"s3\">will <\/span><span class=\"s1\">use what you tell us as we begin to get to know your child and <\/span><span class=\"s4\">p<\/span><span class=\"s5\">l<\/span><span class=\"s3\">a<\/span><span class=\"s1\">n<\/span> <span class=\"s3\">wa<\/span><span class=\"s6\">y<\/span><span class=\"s1\">s<\/span> <span class=\"s3\">t<\/span><span class=\"s1\">o<\/span> <span class=\"s7\">m<\/span><span class=\"s1\">eet<\/span><span class=\"s3\"> hi<\/span><span class=\"s1\">s<\/span><span class=\"s3\">\/<\/span><span class=\"s4\">h<\/span><span class=\"s1\">er<\/span> <span class=\"s3\">n<\/span><span class=\"s2\">e<\/span><span class=\"s1\">e<\/span><span class=\"s6\">d<\/span><span class=\"s1\">s<\/span><span class=\"s3\"> and t<\/span><span class=\"s1\">o <\/span><span class=\"s3\">h<\/span><span class=\"s2\">e<\/span><span class=\"s6\">l<\/span><span class=\"s1\">p<\/span> <span class=\"s3\">h<\/span><span class=\"s4\">i<\/span><span class=\"s5\">m<\/span><span class=\"s3\">\/h<\/span><span class=\"s1\">er develop.<\/span> <span class=\"s1\">Please<\/span> <span class=\"s1\">return<\/span> <span class=\"s1\">it<\/span> <span class=\"s1\">to<\/span> <span class=\"s1\">school<\/span> <span class=\"s1\">as<\/span> <span class=\"s1\">soon<\/span> <span class=\"s1\">as<\/span> <span class=\"s1\">possible.<\/span><\/p>\n<p class=\"p5\"><span class=\"s1\">Thanks so much!<\/span><\/p><\/li><li id=\"field_24_3\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_3'>Childs Name<\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_24_3' type='text' value='' class='medium'   tabindex='1'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_4\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_4'>Childs Nickname<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_24_4' type='text' value='' class='medium'   tabindex='2'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_5\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_5'>Parents\u2019 Names<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_24_5' type='text' value='' class='medium'   tabindex='3'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_6\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_6'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_6' id='input_24_6' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='4'  placeholder='mm\/dd\/aaaa' aria-describedby=\"input_24_6_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_24_6_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_24_6' class='gform_hidden' value='https:\/\/youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_24_7\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_7'>Child\u2019s Teacher<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_24_7' type='text' value='' class='medium'   tabindex='5'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_8\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Does your child live with?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_24_8'><li class='gchoice gchoice_24_8_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.1' type='checkbox'  value='Both Parents'  id='choice_24_8_1' tabindex='6'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_8_1' id='label_24_8_1' class='gform-field-label gform-field-label--type-inline'>Both Parents<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_24_8_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.2' type='checkbox'  value='One Parent'  id='choice_24_8_2' tabindex='7'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_8_2' id='label_24_8_2' class='gform-field-label gform-field-label--type-inline'>One Parent<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_24_8_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.3' type='checkbox'  value='Other adults'  id='choice_24_8_3' tabindex='8'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_8_3' id='label_24_8_3' class='gform-field-label gform-field-label--type-inline'>Other adults<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_9\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_9'>Please Specify<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_9' id='input_24_9' class='textarea medium' tabindex='9'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_10\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_10'>Please list the names and ages of others who live in your home. (This will help me write names correctly on pictures your child draws about his\/her family.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_10' id='input_24_10' class='textarea medium' tabindex='10'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_11\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_11'>Pets (Name &amp; type of animal)<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_24_11' type='text' value='' class='medium'   tabindex='11'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_12\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_12'>Father\u2019s Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_24_12' type='text' value='' class='medium'   tabindex='12'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_13\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_13'>Mother&#039;s Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_24_13' type='text' value='' class='medium'   tabindex='13'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_14\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Does your child have a room of his own?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_24_14'><li class='gchoice gchoice_24_14_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.1' type='checkbox'  value='Yes'  id='choice_24_14_1' tabindex='14'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_14_1' id='label_24_14_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_24_14_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.2' type='checkbox'  value='No'  id='choice_24_14_2' tabindex='15'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_14_2' id='label_24_14_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_15\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_15'>If not, with whom does he\/she share a room?<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_24_15' type='text' value='' class='medium'   tabindex='16'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_16\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_16'>What are your child\u2019s favourite play activities and interests?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_16' id='input_24_16' class='textarea medium' tabindex='17'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_17\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_17'>Does child use special words to go to the bathroom?<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_24_17' type='text' value='' class='medium'   tabindex='18'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_18\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_18'>Child\u2019s favorite TV programs<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_18' id='input_24_18' class='textarea medium' tabindex='19'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_19\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_19'>Hours per day spent watching TV<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_24_19' type='text' value='' class='medium'   tabindex='20'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_20\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Does your child usually play<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_24_20'><li class='gchoice gchoice_24_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='Alone?'  id='choice_24_20_1' tabindex='21'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_20_1' id='label_24_20_1' class='gform-field-label gform-field-label--type-inline'>Alone?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_24_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='With a friend?'  id='choice_24_20_2' tabindex='22'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_20_2' id='label_24_20_2' class='gform-field-label gform-field-label--type-inline'>With a friend?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_24_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='With a few friend?'  id='choice_24_20_3' tabindex='23'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_20_3' id='label_24_20_3' class='gform-field-label gform-field-label--type-inline'>With a few friend?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_24_20_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.4' type='checkbox'  value='with younger children?'  id='choice_24_20_4' tabindex='24'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_20_4' id='label_24_20_4' class='gform-field-label gform-field-label--type-inline'>with younger children?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_24_20_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.5' type='checkbox'  value='with older children?'  id='choice_24_20_5' tabindex='25'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_20_5' id='label_24_20_5' class='gform-field-label gform-field-label--type-inline'>with older children?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_24_20_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.6' type='checkbox'  value='with children the same age?'  id='choice_24_20_6' tabindex='26'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_20_6' id='label_24_20_6' class='gform-field-label gform-field-label--type-inline'>with children the same age?<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_21\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_21'>Does child have decided fears?   If so, what?<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_24_21' type='text' value='' class='medium'   tabindex='27'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_22\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_22'>What responsibilities does your child have at home?<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_24_22' type='text' value='' class='medium'   tabindex='28'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_24\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_24'>What is your biggest discipline problem?<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_24_24' type='text' value='' class='medium'   tabindex='29'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_25\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_25'>What is your child\u2019s favorite story or type of story or book?<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_24_25' type='text' value='' class='medium'   tabindex='30'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_26\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_26'>Did your child have a premature or difficult birth that may indicate cognitive delays?<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_24_26' type='text' value='' class='medium'   tabindex='31'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_27\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_27'>Is English the primary language spoken in the home?   If not, what is?<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_24_27' type='text' value='' class='medium'   tabindex='32'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_28\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_28'>Does your child speak any English? \tUnderstand English?<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_24_28' type='text' value='' class='medium'   tabindex='33'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_29\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_29'>How does your child feel about coming to school?<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_24_29' type='text' value='' class='medium'   tabindex='34'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_30\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_30'>What do you hope your child will learn this year?<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_24_30' type='text' value='' class='medium'   tabindex='35'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_31\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_31'>Please make comments about anything else you think I need to know about your child<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_24_31' class='textarea medium' tabindex='36'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_32\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p class=\"p1\"><span class=\"s1\">It is our goal to encourage a sense of belongingness, promote an appreciation of others and enrich children\u2019s experiences by integrating into our curriculum activities and information that reflect our individual children\u2019s background.<span class=\"Apple-converted-space\">\u00a0 <\/span>One way we can do this is by learning about each child\u2019s family background, celebrated holidays, and traditions. Please take a few minutes to share with us your special family days or activities and how they are carried out in your home.<\/span><\/p><\/li><li id=\"field_24_33\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_33'>What languages other than English are spoken by family members around your child?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_33' id='input_24_33' class='textarea medium' tabindex='37'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_34\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_34'>Does your child have any physical or learning disabilities? \tIf so, please describe<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_24_34' class='textarea medium' tabindex='38'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_35\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_35'>Are there any family members with disabilities that may directly impact your child\u2019s daily life (for example, a deaf grandparent, wheelchair bound parent, etc.)?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_24_35' class='textarea medium' tabindex='39'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_36\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_36'>What information about your family\u2019s background and culture would you like to share with us?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_36' id='input_24_36' class='textarea medium' tabindex='40'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_37\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_37'>What are the holidays, special days, or traditions your family partakes in?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_37' id='input_24_37' class='textarea medium' tabindex='41'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_38\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_38'>Are there any special foods, songs, items or symbols you include in your celebration of special family times?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_38' id='input_24_38' class='textarea medium' tabindex='42'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_39\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_39'>Does your child have any dietary restrictions due to allergies, intolerances, family or religious preferences? \tIf yes, what is restricted?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_39' id='input_24_39' class='textarea medium' tabindex='43'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_40\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_40'>Are there any activities from your family\u2019s culture or traditions that you would like to share with your child\u2019s classroom?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_40' id='input_24_40' class='textarea medium' tabindex='44'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_41\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_41'>Are there any activities from your family\u2019s culture or traditions that you would like to share with your child\u2019s classroom?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_41' id='input_24_41' class='textarea medium' tabindex='45'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_42\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_42'>Please make comments about anything else you think I need to know about your child<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_42' id='input_24_42' class='textarea medium' tabindex='46'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_43\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_43'>What are their strengths?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_43' id='input_24_43' class='textarea medium' tabindex='47'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_44\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_44'>What are the areas of weakness? What would you love for your child to get better at?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_44' id='input_24_44' class='textarea medium' tabindex='48'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_45\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_45'>My child learns best when the teacher is\u2026.<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_24_45' type='text' value='' class='medium'   tabindex='49'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_46\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_46'>My child does not work well with\u2026<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_24_46' type='text' value='' class='medium'   tabindex='50'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_47\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_47'>What is the best way to motivate your child?<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_24_47' type='text' value='' class='medium'   tabindex='51'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_48\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_48'>What are you looking forward to at YMIM?<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_24_48' type='text' value='' class='medium'   tabindex='52'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_49\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_49'>How would you like to be involved with your child\u2019s education?<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_24_49' type='text' value='' class='medium'   tabindex='53'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_50\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_50'>What is your preferred method of communication (email, phone call, meeting, note\u2026)___<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_24_50' type='text' value='' class='medium'   tabindex='54'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_51\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/www.youngmindsinmotion.com\/wp-content\/uploads\/2020\/10\/Screenshot-2020-10-22-at-1.20.05-AM.png\"\/ style=\"width:430px; height:150px; margin-top:50px;\"><img decoding=\"async\" src=\"https:\/\/www.youngmindsinmotion.com\/wp-content\/uploads\/2020\/08\/Screenshot-2020-08-01-at-9.44.15-PM.png\"\/ float:right;\"><\/li><li id=\"field_24_52\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_52'>Date ASQ Completed:<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_24_52' type='text' value='' class='medium'   tabindex='55'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_53\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_53'>Child\u2019s date of birth:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_53' id='input_24_53' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='56'  placeholder='mm\/dd\/aaaa' aria-describedby=\"input_24_53_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_24_53_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_24_53' class='gform_hidden' value='https:\/\/youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_24_54\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Child&#039;s Gender<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_54'>\n\t\t\t<li class='gchoice gchoice_24_54_0'>\n\t\t\t\t<input name='input_54' type='radio' value='Boy'  id='choice_24_54_0' tabindex='57'   \/>\n\t\t\t\t<label for='choice_24_54_0' id='label_24_54_0' class='gform-field-label gform-field-label--type-inline'>Boy<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_54_1'>\n\t\t\t\t<input name='input_54' type='radio' value='Girl'  id='choice_24_54_1' tabindex='58'   \/>\n\t\t\t\t<label for='choice_24_54_1' id='label_24_54_1' class='gform-field-label gform-field-label--type-inline'>Girl<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_55\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Person filling out Questionnaire<\/h3><\/li><li id=\"field_24_56\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_56'>First Name<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_24_56' type='text' value='' class='medium'   tabindex='59'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_57\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_57'>Middle Initial<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_24_57' type='text' value='' class='medium'   tabindex='60'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_58\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_58'>Last name<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_24_58' type='text' value='' class='medium'   tabindex='61'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_59\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_59'>Street Relationship to child:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_59' id='input_24_59' class='textarea medium' tabindex='62'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_60\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Relationship to child:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_60'>\n\t\t\t<li class='gchoice gchoice_24_60_0'>\n\t\t\t\t<input name='input_60' type='radio' value='Parent'  id='choice_24_60_0' tabindex='63'   \/>\n\t\t\t\t<label for='choice_24_60_0' id='label_24_60_0' class='gform-field-label gform-field-label--type-inline'>Parent<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_60_1'>\n\t\t\t\t<input name='input_60' type='radio' value='Guardian'  id='choice_24_60_1' tabindex='64'   \/>\n\t\t\t\t<label for='choice_24_60_1' id='label_24_60_1' class='gform-field-label gform-field-label--type-inline'>Guardian<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_60_2'>\n\t\t\t\t<input name='input_60' type='radio' value='Teacher'  id='choice_24_60_2' tabindex='65'   \/>\n\t\t\t\t<label for='choice_24_60_2' id='label_24_60_2' class='gform-field-label gform-field-label--type-inline'>Teacher<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_60_3'>\n\t\t\t\t<input name='input_60' type='radio' value='Child Care Provider'  id='choice_24_60_3' tabindex='66'   \/>\n\t\t\t\t<label for='choice_24_60_3' id='label_24_60_3' class='gform-field-label gform-field-label--type-inline'>Child Care Provider<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_60_4'>\n\t\t\t\t<input name='input_60' type='radio' value='Grandparent or other relative'  id='choice_24_60_4' tabindex='67'   \/>\n\t\t\t\t<label for='choice_24_60_4' id='label_24_60_4' class='gform-field-label gform-field-label--type-inline'>Grandparent or other relative<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_60_5'>\n\t\t\t\t<input name='input_60' type='radio' value='Foster Parent'  id='choice_24_60_5' tabindex='68'   \/>\n\t\t\t\t<label for='choice_24_60_5' id='label_24_60_5' class='gform-field-label gform-field-label--type-inline'>Foster Parent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_61\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_61'>City :<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_24_61' type='text' value='' class='medium'   tabindex='69'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_62\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_62'>State \/ Province:<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_24_62' type='text' value='' class='medium'   tabindex='70'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_63\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_63'>Zip \/ Postal Code:<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_24_63' type='text' value='' class='medium'   tabindex='71'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_64\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_64'>Country<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_24_64' type='text' value='' class='medium'   tabindex='72'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_65\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_65'>Home telephone number:<\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_24_65' type='text' value='' class='medium'   tabindex='73'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_66\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_66'>Other telephone number:<\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_24_66' type='text' value='' class='medium'   tabindex='74'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_67\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_67'>Email Address<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_24_67' type='text' value='' class='medium'   tabindex='75'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_68\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_68'>Name of the people assisting in questionnaire completion:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_68' id='input_24_68' class='textarea medium' tabindex='76'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_69\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Program Information <\/h3><\/li><li id=\"field_24_70\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_70'>Child ID #<\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_24_70' type='text' value='' class='medium'   tabindex='77'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_71\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_71'>Program ID #<\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_24_71' type='text' value='' class='medium'   tabindex='78'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_72\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_72'>Program Name<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_24_72' type='text' value='' class='medium'   tabindex='79'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_73\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Important Points to Remember:<\/h2>\n<ul>\n    <li>Try each activity with your child before marking a response.<\/li>\n<li>Make completing this questionnaire a game that is fun for you and your child.<\/li>\n<li>Make sure your child is not tired or hungry.<\/li>\n<li>Please return this questionnaire by ________________________<\/li><\/li><li id=\"field_24_74\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_74'>Notes<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_74' id='input_24_74' class='textarea medium' tabindex='80'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_75\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >1. Does your child tell you at least two things about common objects? For example, if you say to you chid, \u201c tell me about your bal. \u201c does se say something like, \u201cIts\u2019 round. It\u2019s round. I throw it. Its\u2019s big\u201d<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_75'>\n\t\t\t<li class='gchoice gchoice_24_75_0'>\n\t\t\t\t<input name='input_75' type='radio' value='Yes'  id='choice_24_75_0' tabindex='81'   \/>\n\t\t\t\t<label for='choice_24_75_0' id='label_24_75_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_75_1'>\n\t\t\t\t<input name='input_75' type='radio' value='Sometime'  id='choice_24_75_1' tabindex='82'   \/>\n\t\t\t\t<label for='choice_24_75_1' id='label_24_75_1' class='gform-field-label gform-field-label--type-inline'>Sometime<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_75_2'>\n\t\t\t\t<input name='input_75' type='radio' value='Not Yet'  id='choice_24_75_2' tabindex='83'   \/>\n\t\t\t\t<label for='choice_24_75_2' id='label_24_75_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_76\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >2. Does your child use all of the words in a sentence ( for example, \u201c a, \u201d \u201cthe\u201d,\u201dam,\u201d \u201dis\u201d and \u201c are \u201d) to make complete sentences, such as \u201c I am going to the park,\u201d \u201cIs there a top to play with?\u201d Or \u201c Are you coming, too?\u201d<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_76'>\n\t\t\t<li class='gchoice gchoice_24_76_0'>\n\t\t\t\t<input name='input_76' type='radio' value='Yes'  id='choice_24_76_0' tabindex='84'   \/>\n\t\t\t\t<label for='choice_24_76_0' id='label_24_76_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_76_1'>\n\t\t\t\t<input name='input_76' type='radio' value='Sometime'  id='choice_24_76_1' tabindex='85'   \/>\n\t\t\t\t<label for='choice_24_76_1' id='label_24_76_1' class='gform-field-label gform-field-label--type-inline'>Sometime<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_76_2'>\n\t\t\t\t<input name='input_76' type='radio' value='Not Yet'  id='choice_24_76_2' tabindex='86'   \/>\n\t\t\t\t<label for='choice_24_76_2' id='label_24_76_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_80\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >3. Does your child use endings of words, such as \u201c-s,&quot; &quot;-ed,\u201d and \u201c-ing&quot;? For example, does your child say things like, \u201cI see two cats,\u201d \u201clam playing,\u201d or \u201cI kicked the ball\u201d?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_80'>\n\t\t\t<li class='gchoice gchoice_24_80_0'>\n\t\t\t\t<input name='input_80' type='radio' value='Yes'  id='choice_24_80_0' tabindex='87'   \/>\n\t\t\t\t<label for='choice_24_80_0' id='label_24_80_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_80_1'>\n\t\t\t\t<input name='input_80' type='radio' value='Sometime'  id='choice_24_80_1' tabindex='88'   \/>\n\t\t\t\t<label for='choice_24_80_1' id='label_24_80_1' class='gform-field-label gform-field-label--type-inline'>Sometime<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_80_2'>\n\t\t\t\t<input name='input_80' type='radio' value='Not Yet'  id='choice_24_80_2' tabindex='89'   \/>\n\t\t\t\t<label for='choice_24_80_2' id='label_24_80_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_78\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >4. Without giving your child help by pointing or repeating directions,  does he follow three directions that are unrelated to one another? Give all three directions before your child starts. For example, you may ask your child, \u201cClap your hands, walk to the door, and sit down,\u201d or &quot;Give me the pen, open the book, and stand up.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_78'>\n\t\t\t<li class='gchoice gchoice_24_78_0'>\n\t\t\t\t<input name='input_78' type='radio' value='Yes'  id='choice_24_78_0' tabindex='90'   \/>\n\t\t\t\t<label for='choice_24_78_0' id='label_24_78_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_78_1'>\n\t\t\t\t<input name='input_78' type='radio' value='Sometime'  id='choice_24_78_1' tabindex='91'   \/>\n\t\t\t\t<label for='choice_24_78_1' id='label_24_78_1' class='gform-field-label gform-field-label--type-inline'>Sometime<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_78_2'>\n\t\t\t\t<input name='input_78' type='radio' value='Not Yet'  id='choice_24_78_2' tabindex='92'   \/>\n\t\t\t\t<label for='choice_24_78_2' id='label_24_78_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_79\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_79'>5. Does your child use four- and five-word sentences? For example, does  your child say, \u201d! want the car\u201d? Please write an example:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_79' id='input_24_79' class='textarea medium' tabindex='93'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_81\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_81'>6. When talking about something that already happened, does your child  use words that end in \u201c-ed,\u201d such as \u201cwalked,\u201d \u201cjumped,\u201d or \u201cplayed\u201d? Ask your child questions, such as \u201cHow did you get to the store?\u201d (\u201cWe walked.\u201d) \u201cWhat did you do at your friend\u2018\u2019s house?\u201d (\u201cWe played.\u201d) Please write an example:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_81' id='input_24_81' class='textarea medium' tabindex='94'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_82\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_82'>Communication Total<\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_24_82' type='text' value='' class='medium'   tabindex='95'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_83\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3> Gross Motors<\/li><li id=\"field_24_84\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >1. Does your child hop up and down on either the right foot or the left  foot at least one time without losing her balance or falling?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_84'>\n\t\t\t<li class='gchoice gchoice_24_84_0'>\n\t\t\t\t<input name='input_84' type='radio' value='Yes'  id='choice_24_84_0' tabindex='96'   \/>\n\t\t\t\t<label for='choice_24_84_0' id='label_24_84_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_84_1'>\n\t\t\t\t<input name='input_84' type='radio' value='Sometimes'  id='choice_24_84_1' tabindex='97'   \/>\n\t\t\t\t<label for='choice_24_84_1' id='label_24_84_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_84_2'>\n\t\t\t\t<input name='input_84' type='radio' value='Not Yet'  id='choice_24_84_2' tabindex='98'   \/>\n\t\t\t\t<label for='choice_24_84_2' id='label_24_84_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_85\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >2. While standing, does your child throw a ball overhand in the direction of a person standing at least 6 feet away? To throw _t overhand, your child must raise his arm to shoulder height and throw the ball forward. (Dropping the ball or throwing the ball underhand should be scored as \u201cnot yet.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_85'>\n\t\t\t<li class='gchoice gchoice_24_85_0'>\n\t\t\t\t<input name='input_85' type='radio' value='Yes'  id='choice_24_85_0' tabindex='99'   \/>\n\t\t\t\t<label for='choice_24_85_0' id='label_24_85_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_85_1'>\n\t\t\t\t<input name='input_85' type='radio' value='Sometimes'  id='choice_24_85_1' tabindex='100'   \/>\n\t\t\t\t<label for='choice_24_85_1' id='label_24_85_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_85_2'>\n\t\t\t\t<input name='input_85' type='radio' value='Not Yet'  id='choice_24_85_2' tabindex='101'   \/>\n\t\t\t\t<label for='choice_24_85_2' id='label_24_85_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_86\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img src = \"https:\/\/www.youngmindsinmotion.com\/wp-content\/uploads\/2020\/08\/Screenshot-2020-08-01-at-6.36.06-PM.png \"  style=\"width:20%;\"><\/li><li id=\"field_24_87\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >3. Does your child jump forward a distance of 20 inches from a standing  position, starting with her feet together?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_87'>\n\t\t\t<li class='gchoice gchoice_24_87_0'>\n\t\t\t\t<input name='input_87' type='radio' value='Yes'  id='choice_24_87_0' tabindex='102'   \/>\n\t\t\t\t<label for='choice_24_87_0' id='label_24_87_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_87_1'>\n\t\t\t\t<input name='input_87' type='radio' value='Sometimes'  id='choice_24_87_1' tabindex='103'   \/>\n\t\t\t\t<label for='choice_24_87_1' id='label_24_87_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_87_2'>\n\t\t\t\t<input name='input_87' type='radio' value='Not Yet'  id='choice_24_87_2' tabindex='104'   \/>\n\t\t\t\t<label for='choice_24_87_2' id='label_24_87_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_88\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >4. Does your child catch a large ball with both hands? should stand about 5 feet away and give your child two or ant three tries before you mark the answer.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_88'>\n\t\t\t<li class='gchoice gchoice_24_88_0'>\n\t\t\t\t<input name='input_88' type='radio' value='Yes'  id='choice_24_88_0' tabindex='105'   \/>\n\t\t\t\t<label for='choice_24_88_0' id='label_24_88_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_88_1'>\n\t\t\t\t<input name='input_88' type='radio' value='Sometimes'  id='choice_24_88_1' tabindex='106'   \/>\n\t\t\t\t<label for='choice_24_88_1' id='label_24_88_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_88_2'>\n\t\t\t\t<input name='input_88' type='radio' value='Not Yet'  id='choice_24_88_2' tabindex='107'   \/>\n\t\t\t\t<label for='choice_24_88_2' id='label_24_88_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_89\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img src =\"https:\/\/www.youngmindsinmotion.com\/wp-content\/uploads\/2020\/08\/Screenshot-2020-08-01-at-8.17.32-PM.png\"  style=\"width:20%;\"><\/li><li id=\"field_24_90\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >5. Without holding onto anything, does your child stand on  one foot for at least 5 seconds without losing her balance and putting her foot down? (You may give your child two or &#039; three tries before you mark the answer.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_90'>\n\t\t\t<li class='gchoice gchoice_24_90_0'>\n\t\t\t\t<input name='input_90' type='radio' value='Yes'  id='choice_24_90_0' tabindex='108'   \/>\n\t\t\t\t<label for='choice_24_90_0' id='label_24_90_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_90_1'>\n\t\t\t\t<input name='input_90' type='radio' value='Sometimes'  id='choice_24_90_1' tabindex='109'   \/>\n\t\t\t\t<label for='choice_24_90_1' id='label_24_90_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_90_2'>\n\t\t\t\t<input name='input_90' type='radio' value='Not Yet'  id='choice_24_90_2' tabindex='110'   \/>\n\t\t\t\t<label for='choice_24_90_2' id='label_24_90_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_91\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img src =\"https:\/\/www.youngmindsinmotion.com\/wp-content\/uploads\/2020\/08\/Screenshot-2020-08-01-at-5.02.30-PM.png\"  style=\"width:20%;\"><\/li><li id=\"field_24_92\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >6. Does your child walk on his tiptoes for 15 feet (about the length of a large car)? (You may show him how to do this.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_92'>\n\t\t\t<li class='gchoice gchoice_24_92_0'>\n\t\t\t\t<input name='input_92' type='radio' value='Yes'  id='choice_24_92_0' tabindex='111'   \/>\n\t\t\t\t<label for='choice_24_92_0' id='label_24_92_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_92_1'>\n\t\t\t\t<input name='input_92' type='radio' value='Sometimes'  id='choice_24_92_1' tabindex='112'   \/>\n\t\t\t\t<label for='choice_24_92_1' id='label_24_92_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_92_2'>\n\t\t\t\t<input name='input_92' type='radio' value='Not Yet'  id='choice_24_92_2' tabindex='113'   \/>\n\t\t\t\t<label for='choice_24_92_2' id='label_24_92_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_93\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_93'>Gross Motor Total<\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_24_93' type='text' value='' class='medium'   tabindex='114'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_94\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Fine Motor <\/h3><\/li><li id=\"field_24_95\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >1.   Using the shapes below to look at, does your child copy at least three shapes onto a large piece of paper using a pencil, crayon, or pen, with- out tracing? (Your child\u2019s drawings should look similar to the design of the shapes below, but they may be different in size.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_95'>\n\t\t\t<li class='gchoice gchoice_24_95_0'>\n\t\t\t\t<input name='input_95' type='radio' value='Yes'  id='choice_24_95_0' tabindex='115'   \/>\n\t\t\t\t<label for='choice_24_95_0' id='label_24_95_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_95_1'>\n\t\t\t\t<input name='input_95' type='radio' value='Sometimes'  id='choice_24_95_1' tabindex='116'   \/>\n\t\t\t\t<label for='choice_24_95_1' id='label_24_95_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_95_2'>\n\t\t\t\t<input name='input_95' type='radio' value='Not Yet'  id='choice_24_95_2' tabindex='117'   \/>\n\t\t\t\t<label for='choice_24_95_2' id='label_24_95_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_96\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/www.youngmindsinmotion.com\/wp-content\/uploads\/2020\/08\/Screenshot-2020-08-01-at-6.43.52-PM.png\"\/ style=\"width:20%;\"><\/li><li id=\"field_24_97\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >2. Does your child unbutton one or more buttons? (Your child may use his own clothing or a doll\u2019s clothing.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_97'>\n\t\t\t<li class='gchoice gchoice_24_97_0'>\n\t\t\t\t<input name='input_97' type='radio' value='Yes'  id='choice_24_97_0' tabindex='118'   \/>\n\t\t\t\t<label for='choice_24_97_0' id='label_24_97_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_97_1'>\n\t\t\t\t<input name='input_97' type='radio' value='Sometimes'  id='choice_24_97_1' tabindex='119'   \/>\n\t\t\t\t<label for='choice_24_97_1' id='label_24_97_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_97_2'>\n\t\t\t\t<input name='input_97' type='radio' value='Not Yet'  id='choice_24_97_2' tabindex='120'   \/>\n\t\t\t\t<label for='choice_24_97_2' id='label_24_97_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_98\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >3.   Does your child color mostly within the lines in a coloring book or within the lines of a 2-inch circle that you draw? (Your child should not go more than 1\/4 inch outside the lines on most of the picture.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_98'>\n\t\t\t<li class='gchoice gchoice_24_98_0'>\n\t\t\t\t<input name='input_98' type='radio' value='Yes'  id='choice_24_98_0' tabindex='121'   \/>\n\t\t\t\t<label for='choice_24_98_0' id='label_24_98_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_98_1'>\n\t\t\t\t<input name='input_98' type='radio' value='Sometimes'  id='choice_24_98_1' tabindex='122'   \/>\n\t\t\t\t<label for='choice_24_98_1' id='label_24_98_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_98_2'>\n\t\t\t\t<input name='input_98' type='radio' value='Not Yet'  id='choice_24_98_2' tabindex='123'   \/>\n\t\t\t\t<label for='choice_24_98_2' id='label_24_98_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_99\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >4. Ask your child to trace on the line below with a pencil. Does your child  trace on the line without going off the line more than two times? (Mark \u201csometimes\u201d if your child goes off the line three times.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_99'>\n\t\t\t<li class='gchoice gchoice_24_99_0'>\n\t\t\t\t<input name='input_99' type='radio' value='Yes'  id='choice_24_99_0' tabindex='124'   \/>\n\t\t\t\t<label for='choice_24_99_0' id='label_24_99_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_99_1'>\n\t\t\t\t<input name='input_99' type='radio' value='Sometimes'  id='choice_24_99_1' tabindex='125'   \/>\n\t\t\t\t<label for='choice_24_99_1' id='label_24_99_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_99_2'>\n\t\t\t\t<input name='input_99' type='radio' value='Not Yet'  id='choice_24_99_2' tabindex='126'   \/>\n\t\t\t\t<label for='choice_24_99_2' id='label_24_99_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_100\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/www.youngmindsinmotion.com\/wp-content\/uploads\/2020\/08\/Screenshot-2020-08-01-at-10.40.31-PM.png\"\/ style=\"width:20%;\"><\/li><li id=\"field_24_101\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >5. Ask your child to draw a picture of a person on a blank sheet of paper.  You may ask your child, \u201cDraw a picture of a girl or a boy.\u201d If your child draws a person with head, body, arms, and legs, mark \u201cyes.\u201d If your child draws a person with only three parts (head, body, arms, or legs), mark \u201csometimes.\u201d If your child draws a person with two or fewer parts (head, body, arms, or legs), mark \u201cnot yet.\u201d Be sure to include the sheet of paper with your child\u2019s drawing with this questionnaire.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_101'>\n\t\t\t<li class='gchoice gchoice_24_101_0'>\n\t\t\t\t<input name='input_101' type='radio' value='Yes'  id='choice_24_101_0' tabindex='127'   \/>\n\t\t\t\t<label for='choice_24_101_0' id='label_24_101_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_101_1'>\n\t\t\t\t<input name='input_101' type='radio' value='Sometimes'  id='choice_24_101_1' tabindex='128'   \/>\n\t\t\t\t<label for='choice_24_101_1' id='label_24_101_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_101_2'>\n\t\t\t\t<input name='input_101' type='radio' value='Not Yet'  id='choice_24_101_2' tabindex='129'   \/>\n\t\t\t\t<label for='choice_24_101_2' id='label_24_101_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_102\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >6. Draw a line across a piece of paper. Using child-safe Um i  scissors does your child cut the paper in half on  more or less straight line, making the blades group _ and down? (Carefully watch your child&#039;s use of scissors for safety reasons.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_102'>\n\t\t\t<li class='gchoice gchoice_24_102_0'>\n\t\t\t\t<input name='input_102' type='radio' value='Yes'  id='choice_24_102_0' tabindex='130'   \/>\n\t\t\t\t<label for='choice_24_102_0' id='label_24_102_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_102_1'>\n\t\t\t\t<input name='input_102' type='radio' value='Sometimes'  id='choice_24_102_1' tabindex='131'   \/>\n\t\t\t\t<label for='choice_24_102_1' id='label_24_102_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_102_2'>\n\t\t\t\t<input name='input_102' type='radio' value='Not Yet'  id='choice_24_102_2' tabindex='132'   \/>\n\t\t\t\t<label for='choice_24_102_2' id='label_24_102_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_103\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_103'>Fine Motor Total<\/label><div class='ginput_container ginput_container_text'><input name='input_103' id='input_24_103' type='text' value='' class='medium'   tabindex='133'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_104\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3> Problem Solving <\/h3><\/li><li id=\"field_24_105\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >1. When shown objects and asked, \u201cWhat color is this?\u201d does your child  name five different colors, like red, blue, yellow, orange, black, white, or pink? (Mark \u201cyes\u201d only if your child answers the question correctly using five colors.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_105'>\n\t\t\t<li class='gchoice gchoice_24_105_0'>\n\t\t\t\t<input name='input_105' type='radio' value='Yes'  id='choice_24_105_0' tabindex='134'   \/>\n\t\t\t\t<label for='choice_24_105_0' id='label_24_105_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_105_1'>\n\t\t\t\t<input name='input_105' type='radio' value='Sometimes'  id='choice_24_105_1' tabindex='135'   \/>\n\t\t\t\t<label for='choice_24_105_1' id='label_24_105_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_105_2'>\n\t\t\t\t<input name='input_105' type='radio' value='Not Yet'  id='choice_24_105_2' tabindex='136'   \/>\n\t\t\t\t<label for='choice_24_105_2' id='label_24_105_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_106\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >2. Does your child dress up and \u201cplay-act,\u201d pretending to be someone or something else? For example, your child may dress up in different clothes and pretend to be a mommy, daddy, brother, sister, or an imaginary animal or figure.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_106'>\n\t\t\t<li class='gchoice gchoice_24_106_0'>\n\t\t\t\t<input name='input_106' type='radio' value='Yes'  id='choice_24_106_0' tabindex='137'   \/>\n\t\t\t\t<label for='choice_24_106_0' id='label_24_106_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_106_1'>\n\t\t\t\t<input name='input_106' type='radio' value='Sometimes'  id='choice_24_106_1' tabindex='138'   \/>\n\t\t\t\t<label for='choice_24_106_1' id='label_24_106_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_106_2'>\n\t\t\t\t<input name='input_106' type='radio' value='Not Yet'  id='choice_24_106_2' tabindex='139'   \/>\n\t\t\t\t<label for='choice_24_106_2' id='label_24_106_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_107\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >3. If you place five objects in front of your child, can she count them by  saying, \u201cOne, two, three, four, five\u201d in order? (Ask this question without providing help by pointing, gesturing, or naming.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_107'>\n\t\t\t<li class='gchoice gchoice_24_107_0'>\n\t\t\t\t<input name='input_107' type='radio' value='Yes'  id='choice_24_107_0' tabindex='140'   \/>\n\t\t\t\t<label for='choice_24_107_0' id='label_24_107_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_107_1'>\n\t\t\t\t<input name='input_107' type='radio' value='Sometimes'  id='choice_24_107_1' tabindex='141'   \/>\n\t\t\t\t<label for='choice_24_107_1' id='label_24_107_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_107_2'>\n\t\t\t\t<input name='input_107' type='radio' value='Not Yet'  id='choice_24_107_2' tabindex='142'   \/>\n\t\t\t\t<label for='choice_24_107_2' id='label_24_107_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_108\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >4. When asked, \u201cWhich circle is smallest?\u201d does your child point to the ) a smallest circle? (Ask this question without providing help by pointing, gesturing, or looking at the smallest circle.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_108'>\n\t\t\t<li class='gchoice gchoice_24_108_0'>\n\t\t\t\t<input name='input_108' type='radio' value='Yes'  id='choice_24_108_0' tabindex='143'   \/>\n\t\t\t\t<label for='choice_24_108_0' id='label_24_108_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_108_1'>\n\t\t\t\t<input name='input_108' type='radio' value='Sometimes'  id='choice_24_108_1' tabindex='144'   \/>\n\t\t\t\t<label for='choice_24_108_1' id='label_24_108_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_108_2'>\n\t\t\t\t<input name='input_108' type='radio' value='Not Yet'  id='choice_24_108_2' tabindex='145'   \/>\n\t\t\t\t<label for='choice_24_108_2' id='label_24_108_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_109\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/www.youngmindsinmotion.com\/wp-content\/uploads\/2020\/10\/Screenshot-2020-10-21-at-10.52.00-PM.png\"\/ style=\"width:20%;\"><\/li><li id=\"field_24_110\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >5. Does you child count up to 15 without making mistakes? If so, mark \u201cyes\u201d If your child counts to 12 without making mistakes, ,ark \u201csome-times.\u201d<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_110'>\n\t\t\t<li class='gchoice gchoice_24_110_0'>\n\t\t\t\t<input name='input_110' type='radio' value='Yes'  id='choice_24_110_0' tabindex='146'   \/>\n\t\t\t\t<label for='choice_24_110_0' id='label_24_110_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_110_1'>\n\t\t\t\t<input name='input_110' type='radio' value='Sometimes'  id='choice_24_110_1' tabindex='147'   \/>\n\t\t\t\t<label for='choice_24_110_1' id='label_24_110_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_110_2'>\n\t\t\t\t<input name='input_110' type='radio' value='Not Yet'  id='choice_24_110_2' tabindex='148'   \/>\n\t\t\t\t<label for='choice_24_110_2' id='label_24_110_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_111\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >6. Does your child know the names of numbers? (Mark \u201cyes\u201d if he identifies the three numbers below. Mark \u201csometimes\u201d if he identifies two numbers.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_111'>\n\t\t\t<li class='gchoice gchoice_24_111_0'>\n\t\t\t\t<input name='input_111' type='radio' value='Yes'  id='choice_24_111_0' tabindex='149'   \/>\n\t\t\t\t<label for='choice_24_111_0' id='label_24_111_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_111_1'>\n\t\t\t\t<input name='input_111' type='radio' value='Sometimes'  id='choice_24_111_1' tabindex='150'   \/>\n\t\t\t\t<label for='choice_24_111_1' id='label_24_111_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_111_2'>\n\t\t\t\t<input name='input_111' type='radio' value='Not Yet'  id='choice_24_111_2' tabindex='151'   \/>\n\t\t\t\t<label for='choice_24_111_2' id='label_24_111_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_112\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/www.youngmindsinmotion.com\/wp-content\/uploads\/2020\/10\/Screenshot-2020-10-22-at-3.14.08-AM.png\"\/ style=\"width:20%;\"><\/li><li id=\"field_24_113\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_113'>Problem Solving Total<\/label><div class='ginput_container ginput_container_text'><input name='input_113' id='input_24_113' type='text' value='' class='medium'   tabindex='152'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_114\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Personal Social <\/h3><\/li><li id=\"field_24_115\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >1. Does your child wash her hands using soap and water and dry off withna towel without help?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_115'>\n\t\t\t<li class='gchoice gchoice_24_115_0'>\n\t\t\t\t<input name='input_115' type='radio' value='Yes'  id='choice_24_115_0' tabindex='153'   \/>\n\t\t\t\t<label for='choice_24_115_0' id='label_24_115_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_115_1'>\n\t\t\t\t<input name='input_115' type='radio' value='Sometimes'  id='choice_24_115_1' tabindex='154'   \/>\n\t\t\t\t<label for='choice_24_115_1' id='label_24_115_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_115_2'>\n\t\t\t\t<input name='input_115' type='radio' value='Not Yet'  id='choice_24_115_2' tabindex='155'   \/>\n\t\t\t\t<label for='choice_24_115_2' id='label_24_115_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_116\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >1. Does your child wash her hands using soap and water and dry off withna towel without help?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_116'>\n\t\t\t<li class='gchoice gchoice_24_116_0'>\n\t\t\t\t<input name='input_116' type='radio' value='Yes'  id='choice_24_116_0' tabindex='156'   \/>\n\t\t\t\t<label for='choice_24_116_0' id='label_24_116_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_116_1'>\n\t\t\t\t<input name='input_116' type='radio' value='Sometimes'  id='choice_24_116_1' tabindex='157'   \/>\n\t\t\t\t<label for='choice_24_116_1' id='label_24_116_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_116_2'>\n\t\t\t\t<input name='input_116' type='radio' value='Not Yet'  id='choice_24_116_2' tabindex='158'   \/>\n\t\t\t\t<label for='choice_24_116_2' id='label_24_116_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_117\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >2. Does your child tell you the names of two or more playmates, not including brothers and sisters? (Ask this question without providing help by suggesting names of playmates or friends.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_117'>\n\t\t\t<li class='gchoice gchoice_24_117_0'>\n\t\t\t\t<input name='input_117' type='radio' value='Yes'  id='choice_24_117_0' tabindex='159'   \/>\n\t\t\t\t<label for='choice_24_117_0' id='label_24_117_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_117_1'>\n\t\t\t\t<input name='input_117' type='radio' value='Sometimes'  id='choice_24_117_1' tabindex='160'   \/>\n\t\t\t\t<label for='choice_24_117_1' id='label_24_117_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_117_2'>\n\t\t\t\t<input name='input_117' type='radio' value='Not Yet'  id='choice_24_117_2' tabindex='161'   \/>\n\t\t\t\t<label for='choice_24_117_2' id='label_24_117_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_118\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >3. Does your child brush his teeth by putting toothpaste on the toothbrush and brushing all of his teeth without help? (You may still need to check and re brush your child&#039;s teeth.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_118'>\n\t\t\t<li class='gchoice gchoice_24_118_0'>\n\t\t\t\t<input name='input_118' type='radio' value='Yes'  id='choice_24_118_0' tabindex='162'   \/>\n\t\t\t\t<label for='choice_24_118_0' id='label_24_118_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_118_1'>\n\t\t\t\t<input name='input_118' type='radio' value='Sometimes'  id='choice_24_118_1' tabindex='163'   \/>\n\t\t\t\t<label for='choice_24_118_1' id='label_24_118_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_118_2'>\n\t\t\t\t<input name='input_118' type='radio' value='Not Yet'  id='choice_24_118_2' tabindex='164'   \/>\n\t\t\t\t<label for='choice_24_118_2' id='label_24_118_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_119\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >4. Does your child serve herself, taking food from one container to another, using utensils? (For example, does your child use a large spoon to scoop applesauce from a jar into a bowl?)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_119'>\n\t\t\t<li class='gchoice gchoice_24_119_0'>\n\t\t\t\t<input name='input_119' type='radio' value='Yes'  id='choice_24_119_0' tabindex='165'   \/>\n\t\t\t\t<label for='choice_24_119_0' id='label_24_119_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_119_1'>\n\t\t\t\t<input name='input_119' type='radio' value='Sometimes'  id='choice_24_119_1' tabindex='166'   \/>\n\t\t\t\t<label for='choice_24_119_1' id='label_24_119_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_119_2'>\n\t\t\t\t<input name='input_119' type='radio' value='Not Yet'  id='choice_24_119_2' tabindex='167'   \/>\n\t\t\t\t<label for='choice_24_119_2' id='label_24_119_2' class='gform-field-label gform-field-label--type-inline'>Not Yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_120\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >5.   Does your child tell you at least four of the following? Please mark the items your child knows.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_120'>\n\t\t\t<li class='gchoice gchoice_24_120_0'>\n\t\t\t\t<input name='input_120' type='radio' value='a. First name'  id='choice_24_120_0' tabindex='168'   \/>\n\t\t\t\t<label for='choice_24_120_0' id='label_24_120_0' class='gform-field-label gform-field-label--type-inline'>a. First name<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_120_1'>\n\t\t\t\t<input name='input_120' type='radio' value='b. Age'  id='choice_24_120_1' tabindex='169'   \/>\n\t\t\t\t<label for='choice_24_120_1' id='label_24_120_1' class='gform-field-label gform-field-label--type-inline'>b. Age<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_120_2'>\n\t\t\t\t<input name='input_120' type='radio' value='c. City she lives in'  id='choice_24_120_2' tabindex='170'   \/>\n\t\t\t\t<label for='choice_24_120_2' id='label_24_120_2' class='gform-field-label gform-field-label--type-inline'>c. City she lives in<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_120_3'>\n\t\t\t\t<input name='input_120' type='radio' value='d. Last Name'  id='choice_24_120_3' tabindex='171'   \/>\n\t\t\t\t<label for='choice_24_120_3' id='label_24_120_3' class='gform-field-label gform-field-label--type-inline'>d. Last Name<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_120_4'>\n\t\t\t\t<input name='input_120' type='radio' value='e. Boy or Girl'  id='choice_24_120_4' tabindex='172'   \/>\n\t\t\t\t<label for='choice_24_120_4' id='label_24_120_4' class='gform-field-label gform-field-label--type-inline'>e. Boy or Girl<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_120_5'>\n\t\t\t\t<input name='input_120' type='radio' value='f. Telephone Number'  id='choice_24_120_5' tabindex='173'   \/>\n\t\t\t\t<label for='choice_24_120_5' id='label_24_120_5' class='gform-field-label gform-field-label--type-inline'>f. Telephone Number<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_121\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >6.   Does your child dress or undress himself without help (except for snaps, buttons, and zippers)?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_24_121'>\n\t\t\t<li class='gchoice gchoice_24_121_0'>\n\t\t\t\t<input name='input_121' type='radio' value='Yes'  id='choice_24_121_0' tabindex='174'   \/>\n\t\t\t\t<label for='choice_24_121_0' id='label_24_121_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_121_1'>\n\t\t\t\t<input name='input_121' type='radio' value='Sometimes'  id='choice_24_121_1' tabindex='175'   \/>\n\t\t\t\t<label for='choice_24_121_1' id='label_24_121_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_24_121_2'>\n\t\t\t\t<input name='input_121' type='radio' value='Not yet'  id='choice_24_121_2' tabindex='176'   \/>\n\t\t\t\t<label for='choice_24_121_2' id='label_24_121_2' class='gform-field-label gform-field-label--type-inline'>Not yet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_24_122\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_122'>Personal Social Total<\/label><div class='ginput_container ginput_container_text'><input name='input_122' id='input_24_122' type='text' value='' class='medium'   tabindex='177'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_24_123\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_123'>1.   Do you think your child hears well? If no, explain:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_123' id='input_24_123' class='textarea medium' tabindex='178'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_124\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_124'>2. Do you think your child talks like other children her age? If no explain<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_124' id='input_24_124' class='textarea medium' tabindex='179'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_125\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_125'>3. Can you understand most of water what your child says? If no, explain<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_125' id='input_24_125' class='textarea medium' tabindex='180'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_126\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_126'>4. Can other people understand most of what your child says?If no, explain<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_126' id='input_24_126' class='textarea medium' tabindex='181'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_127\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_127'>5.   Do you think your child walks, runs, and climbs like other children his  age? If no, explain:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_127' id='input_24_127' class='textarea medium' tabindex='182'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_128\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_128'>6.   Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_128' id='input_24_128' class='textarea medium' tabindex='183'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_129\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_129'>7.   Do you have any concerns about your child\u2019s vision? If yes, explain:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_129' id='input_24_129' class='textarea medium' tabindex='184'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_130\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_130'>8.   Has your child had any medical problems in the last several months? If  yes, explain:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_130' id='input_24_130' class='textarea medium' tabindex='185'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_131\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_131'>9.   Do you have any concerns about your child\u2019s behavior? If yes, explain:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_131' id='input_24_131' class='textarea medium' tabindex='186'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_24_132\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_132'>10.   Does anything about your child worry you? 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