Autism M-CHAT Screening Form
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Autism M-CHAT Screening Form
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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.
How to use the Autism M-CHAT Screening Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Autism M-CHAT Screening Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Autism M-CHAT Screening Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 14 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Autism M-CHAT Screening Form HIPAA compliant?
Yes. All Formisoft templates, including the Autism M-CHAT Screening Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 14 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Autism M-CHAT Screening Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Autism M-CHAT Screening Form for your practice. Set up in minutes.
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