Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Autism M-CHAT Screening Form
Your information
Child's Name
Date of Birth
____ / ____ / ________
Child's Age (months)
Parent/Guardian Name
Points to Show Interest
Interest in Other Children
Responds to Name
Additional details
Makes Eye Contact
Imitates Actions
Follows a Point
Pretend Play
Unusual Sensory Responses
Risk Score Category
Provider Follow-Up Notes
Autism M-CHAT Screening Form template from formisoft.com. formisoft.com/intake-templates/autism-mchat-screening