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Autism M-CHAT Screening Form
Screening

Autism M-CHAT Screening Form

2 pages•24 fields•HIPAA-ready
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Autism M-CHAT Screening Form
Child's Name
Date of Birth
Child's Age (months)
Parent/Guardian Name
Points to Show Interest
Interest in Other Children
Responds to Name
Makes Eye Contact
Imitates Actions
Follows a Point
Pretend Play
Unusual Sensory Responses
Risk Score Category
Select...
Provider Follow-Up Notes
Submit
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The Autism M-CHAT Screening Form is based on the Modified Checklist for Autism in Toddlers (M-CHAT-R), a validated parent-report screening instrument designed to identify children at risk for autism spectrum disorder (ASD) between 16 and 30 months of age. This form presents the standardized set of yes/no questions that assess key behavioral indicators including joint attention, social referencing, imitation, response to name, and interest in other children.

The form is structured to guide parents through each screening question with clear, simple language and concrete examples. It includes a scoring section that categorizes results into low-risk, medium-risk, and high-risk tiers to help providers determine appropriate follow-up actions. For medium-risk scores, the form includes follow-up interview prompts that reduce false-positive rates and improve screening specificity.

Recommended by the American Academy of Pediatrics for universal screening at the 18-month and 24-month well-child visits, this form is essential for pediatric practices, family medicine clinics, early intervention programs, and developmental pediatrics centers. Early identification through M-CHAT screening enables timely referral for comprehensive diagnostic evaluation and access to early behavioral interventions that significantly improve long-term outcomes.

What's included

  • Complete M-CHAT-R standardized screening questions
  • Parent-friendly question format with concrete examples
  • Automated risk-tier scoring (low, medium, high)
  • Follow-up interview prompts for medium-risk results
  • Referral recommendation guidance based on score
  • Child demographic and developmental history fields

Who uses this template

  • Universal autism screening at 18-month and 24-month well-child visits
  • Follow-up screening for children with developmental concerns
  • Early intervention program intake and eligibility assessment
  • Developmental pediatrics referral documentation

All form fields

14 fields across 2 pages. Customize any field after signing up.

Child's NameText
Date of BirthDate
Child's Age (months)Number
Parent/Guardian NameText
Points to Show InterestMultiple Choice
Interest in Other ChildrenMultiple Choice
Responds to NameMultiple Choice
Makes Eye ContactMultiple Choice
Imitates ActionsMultiple Choice
Follows a PointMultiple Choice
Pretend PlayMultiple Choice
Unusual Sensory ResponsesMultiple Choice
Risk Score CategoryDropdown
Provider Follow-Up NotesLong Text

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