SPROUT Screener SPROUT Screener Eligibility screener for SPROUT study Consent*Before completing this survey we need your consent to gather information about you and your child. This information will be used to determine whether they are eligible to participate in this study. The purpose of this study is to investigate changes in expressive language and social communication in children over the course of a play-based intervention. Participation is completely voluntary. You will be asked to provide information about you or your child's health/developmental history, language, and behavior. You don't have to answer any questions you don't want to and you can stop filling out this form at any point. Any information you provide will be kept confidential. Do you consent to continue with this form? Yes, I consent No, I do not consent No, I prefer to complete an eligibility interview over the phone Today's Date* MM slash DD slash YYYY Caregiver's Name* First Last Your Relation to the Participant (Your Child)?* Biological Mother Biological Father Non-Biological Mother Non-Biological Father Please describe your relationship to the child E.g., step-mother, adoptive fatherChild's (Participant) Full Name* First Last Child's Middle Name Child's Gender* Female Male Non-binary Prefer not to respond Child's Age* Year; monthsChild's Date of Birth* Month Day Year Child's City of Birth Child's Ethnicity* Hispanic Non-Hispanic Prefer not to respond Child's Race* American Indian/ Alaska Native Asian Black of African American Hispanic Native Hawaiian or Other Pacific Islander White More than one race Prefer not to respond Child's primary language?*Language the participant hears or speaks the most. Describe child's primary language* Does the participant have a diagnosis or suspected of autism (ASD, PDD-NOS, Asperger's)?* Yes No Please describe your child's diagnosis How does your child communicate when they want something?How does your child communicate?* Speech sounds No to some words Phrase Speech Full sentences Please provide us with an example of what your child says on a typical day to you?Does the participant, or any of his/her siblings, have any other developmental/medical/psychiatric diagnoses? Yes No If your child, or any of his/her siblings, have any other developmental/medical/psychiatric diagnoses, please specify here (which diagnoses):Address* Street Address City State / Province / Region ZIP / Postal Code Your Primary Address (Street address, City, State, Zip Code)Cell Phone*Work Phone Email* Preferred Method of Contact* Cell Phone Work Phone Email Other Please describe preferred method of contact* What is the best time of day to reach you?* Anytime Morning Afternoon Evening Other Please describe your preferred time for contact How did you hear about us?