Project ECHO Screener Form Project ECHO Eligibility Form This form is used to determine initial eligibility for Project ECHO. Step 1 of 2 50% ConsentWe need your consent to gather information about you and your child. This information will be used to determine whether you are eligible to participate in this study. You don't have to answer any questions you don't want to and you can stop filling out this form at any point. All information provided by you will be kept confidential. Only our project staff will have access to the information for research purposes. Do you consent to answering these questions so we can know more about you and your child? If you prefer to complete our eligibility screener over the phone, you can contact the project ECHO research team at echocare@bu.edu or 617-358-4474. Yes, I consent. No, I do not consent. Today's Date(Required) Month Day Year Your Name(Required) First Last Your relationship to the child?(Required) Biological mother Biological father Non-biological mother Non-biological father Other Email(Required) Phone Number(Required) Please select your preferred method of contact(Required) Phone call Text message Email Child's Full Name(Required) First Last Child's Date of Birthday(Required) Month Day Year Child's age(Required)years, months Child's Sex(Required) Female Male Other or prefer not to respond Is English the primary language spoken to your child at home?(Required) Yes No What percentage of time does your child hear English?(Required)Was your child carried full-term to 32 weeks or more?(Required) Yes No At how many weeks was your child born?(Required) Does your child have any developmental disorders or disabilities, such as autism or ADHD(Required) Yes No Has your child received an official diagnosis of Autism Spectrum Disorder, Asperger's Syndrome, or PDD-NOS?(Required) Do you have any concerns about your child's development, or has a health professional ever expressed concerns about your child's speech or language development?(Required) Yes No How many spoken words does your child have?(Required)Echoed words count! Zero 1-20 21-49 50+ Does your child have any genetic syndromes?(Required) Yes No Does your child have a seizure disorder?(Required) Yes No Has your child ever had a sever head injury or traumatic brain injury?(Required) Yes No Does your child have any siblings or first-degree relatives with a known developmental disorder, such as autism(Required) Yes No Does your child have: Food allergies or dietary restrictions? Sensory sensitivities? Any aversions to wearing a hat? Self-injurious or aggressive behaviors? What foods are restricted?(Required) Please describe any sensory sensitivities(Required) Please describe self-injurious or aggressive behaviors(Required) What does your child like as rewards?(Required)For example: positive praise, snacks, specific toys Is there anything else we should know that will help us understand how to best work with your child?