formisoft
Screening

Autism M-CHAT Screening Form

2 pages•14 fields•HIPAA-ready
Ready to useHIPAA compliantCustomize in minutes
Use this templateBrowse all templates

Form preview

formisoft.com/f/autism-mchat-screening

Autism M-CHAT Screening Form

Page 1 of 2

Child's Name
Jane Martinez
Date of Birth
03/15/1985
Child's Age (months)
0
Parent/Guardian Name
Jane Martinez
Points to Show Interest
Option A
Option B
Option C
Interest in Other Children
Option A
Option B
Option C
Responds to Name
Option A
Option B
Option C
Makes Eye Contact
Option A
Option B
Option C
Imitates Actions
Option A
Option B
Option C
Follows a Point
Option A
Option B
Option C
Pretend Play
Option A
Option B
Option C
Unusual Sensory Responses
Option A
Option B
Option C
Risk Score Category
Select an option...
Provider Follow-Up Notes
Enter details here...
Submit
Use this template

Sign up and start customizing in minutes.

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
8 min saved per patient98% patient satisfaction3x faster than paper

Start with this template

Sign up and start customizing the Autism M-CHAT Screening Form for your practice. Set up in minutes.

Use this templateBrowse all templates

Related templates

Child's Name
Date of Birth
Child's Age (months)
Parent/Guardian Name
Gestational Age at Birth
Screening

Pediatric Developmental Screening Form

Age-appropriate developmental milestone screening form for pediatric patients, assessing communication, motor skills, social-emotional development, and cognitive milestones.

3 pages•14 fields
Child's Name & Date of Birth
Phone Number
Email Address
Parent/Guardian Information
Birth History (Weight, Delivery Type)
Intake
Popular

Pediatric Intake Form

Child-specific intake form with developmental milestones, immunization records, birth history, school information, and parent/guardian details. Designed for pediatric and family medicine practices.

3 pages•13 fields
ACE (Adverse Childhood Experiences) Screening
Patient Name
Date of Birth
Emotional Abuse
Physical Abuse
Sexual Abuse
Screening

ACE (Adverse Childhood Experiences) Screening

Standardized Adverse Childhood Experiences (ACE) screening questionnaire assessing 10 categories of childhood adversity. Used to identify trauma history and inform trauma-informed care approaches.

2 pages•14 fields
Autism M-CHAT Screening FormUse this template