{"id":3828,"date":"2020-10-21T15:36:23","date_gmt":"2020-10-21T19:36:23","guid":{"rendered":"https:\/\/staging.youngmindsinmotion.com\/?page_id=3828"},"modified":"2020-10-21T19:04:35","modified_gmt":"2020-10-21T23:04:35","slug":"48-month-assessment","status":"publish","type":"page","link":"https:\/\/staging.youngmindsinmotion.com\/es\/48-month-assessment\/","title":{"rendered":"Evaluaci\u00f3n de 48 meses"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"3828\" class=\"elementor elementor-3828\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-15dc901 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"15dc901\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-6593ccb\" data-id=\"6593ccb\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-0560fee elementor-widget elementor-widget-wp-widget-gform_widget\" data-id=\"0560fee\" data-element_type=\"widget\" data-widget_type=\"wp-widget-gform_widget.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<link rel='stylesheet' id='gforms_reset_css-css' href='https:\/\/staging.youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/legacy\/css\/formreset.min.css?ver=2.9.22' media='all' \/>\n<link rel='stylesheet' id='gforms_datepicker_css-css' href='https:\/\/staging.youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/legacy\/css\/datepicker.min.css?ver=2.9.22' media='all' \/>\n<link rel='stylesheet' id='gforms_formsmain_css-css' href='https:\/\/staging.youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/legacy\/css\/formsmain.min.css?ver=2.9.22' media='all' \/>\n<link rel='stylesheet' id='gforms_ready_class_css-css' href='https:\/\/staging.youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/legacy\/css\/readyclass.min.css?ver=2.9.22' media='all' \/>\n<link rel='stylesheet' id='gforms_browsers_css-css' href='https:\/\/staging.youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/legacy\/css\/browsers.min.css?ver=2.9.22' media='all' \/>\n<script src=\"https:\/\/staging.youngmindsinmotion.com\/wp-includes\/js\/dist\/dom-ready.min.js?ver=f77871ff7694fffea381\" id=\"wp-dom-ready-js\"><\/script>\n<script src=\"https:\/\/staging.youngmindsinmotion.com\/wp-includes\/js\/dist\/hooks.min.js?ver=4d63a3d491d11ffd8ac6\" id=\"wp-hooks-js\"><\/script>\n<script src=\"https:\/\/staging.youngmindsinmotion.com\/wp-includes\/js\/dist\/i18n.min.js?ver=5e580eb46a90c2b997e6\" id=\"wp-i18n-js\"><\/script>\n<script id=\"wp-i18n-js-after\">\nwp.i18n.setLocaleData( { 'text direction\\u0004ltr': [ 'ltr' ] } );\n<\/script>\n<script id=\"wp-a11y-js-translations\">\n( function( domain, translations ) {\n\tvar localeData = translations.locale_data[ domain ] || translations.locale_data.messages;\n\tlocaleData[\"\"].domain = domain;\n\twp.i18n.setLocaleData( localeData, domain );\n} )( \"default\", {\"translation-revision-date\":\"2026-06-13 15:23:21+0000\",\"generator\":\"GlotPress\\\/4.0.3\",\"domain\":\"messages\",\"locale_data\":{\"messages\":{\"\":{\"domain\":\"messages\",\"plural-forms\":\"nplurals=2; plural=n != 1;\",\"lang\":\"es\"},\"Notifications\":[\"Avisos\"]}},\"comment\":{\"reference\":\"wp-includes\\\/js\\\/dist\\\/a11y.js\"}} );\n<\/script>\n<script src=\"https:\/\/staging.youngmindsinmotion.com\/wp-includes\/js\/dist\/a11y.min.js?ver=3156534cc54473497e14\" id=\"wp-a11y-js\"><\/script>\n<script src=\"https:\/\/staging.youngmindsinmotion.com\/wp-includes\/js\/jquery\/jquery.min.js?ver=3.7.1\" id=\"jquery-core-js\"><\/script>\n<script src=\"https:\/\/staging.youngmindsinmotion.com\/wp-includes\/js\/jquery\/jquery-migrate.min.js?ver=3.4.1\" id=\"jquery-migrate-js\"><\/script>\n<script defer='defer' src=\"https:\/\/staging.youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/js\/jquery.json.min.js?ver=2.9.22\" id=\"gform_json-js\"><\/script>\n<script id=\"gform_gravityforms-js-extra\">\nvar gf_global = {\"gf_currency_config\":{\"name\":\"D\\u00f3lar Americano\",\"symbol_left\":\"$\",\"symbol_right\":\"\",\"symbol_padding\":\"\",\"thousand_separator\":\",\",\"decimal_separator\":\".\",\"decimals\":2,\"code\":\"USD\"},\"base_url\":\"https:\\\/\\\/staging.youngmindsinmotion.com\\\/wp-content\\\/plugins\\\/gravityforms\",\"number_formats\":[],\"spinnerUrl\":\"https:\\\/\\\/staging.youngmindsinmotion.com\\\/wp-content\\\/plugins\\\/gravityforms\\\/images\\\/spinner.svg\",\"version_hash\":\"44a7bcf70cd85b92321700f106746aeb\",\"strings\":{\"newRowAdded\":\"Nueva fila a\\u00f1adida.\",\"rowRemoved\":\"Fila eliminada\",\"formSaved\":\"Se ha guardado el formulario. El contenido incluye el enlace para volver y completar el formulario.\"}};\n<\/script>\n<script defer='defer' src=\"https:\/\/staging.youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/js\/gravityforms.min.js?ver=2.9.22\" id=\"gform_gravityforms-js\"><\/script>\n<script src=\"https:\/\/staging.youngmindsinmotion.com\/wp-includes\/js\/jquery\/ui\/core.min.js?ver=1.13.3\" id=\"jquery-ui-core-js\"><\/script>\n<script src=\"https:\/\/staging.youngmindsinmotion.com\/wp-includes\/js\/jquery\/ui\/datepicker.min.js?ver=1.13.3\" id=\"jquery-ui-datepicker-js\"><\/script>\n<script defer='defer' src=\"https:\/\/staging.youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/js\/datepicker-legacy.min.js?ver=2.9.22\" id=\"gform_datepicker_legacy-js\"><\/script>\n<script defer='defer' src=\"https:\/\/staging.youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/js\/datepicker.min.js?ver=2.9.22\" id=\"gform_datepicker_init-js\"><\/script>\n<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_23' ><form method='post' enctype='multipart\/form-data'  id='gform_23'  action='\/es\/wp-json\/wp\/v2\/pages\/3828' data-formid='23' novalidate data-trp-original-action=\"\/es\/wp-json\/wp\/v2\/pages\/3828\">\n                        <div class='gform-body gform_body'><ul id='gform_fields_23' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_23_1\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/www.youngmindsinmotion.com\/wp-content\/uploads\/2016\/09\/YMIM-logo-2.png\" width=\"247\" height=\"90\" >\n<h2 style=\"text-align:center;\">CUESTIONARIO PARA PADRES\n<\/h2>\n<\/li><li id=\"field_23_2\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p class=\"p1\"><span class=\"s1\">Queridos padres,<\/span><\/p>\n<p class=\"p3\"><span class=\"s1\">Ay\u00fadenos a conocer a su hijo <\/span><span class=\"s2\">por <\/span><span class=\"s1\">llenando este formulario. <\/span><span class=\"s3\">Todas <\/span><span class=\"s1\">la informaci\u00f3n ser\u00e1 confidencial. Nosotros <\/span><span class=\"s3\">ser\u00e1 <\/span><span class=\"s1\">Use lo que nos dice a medida que comenzamos a conocer a su hijo y <\/span><span class=\"s4\">pags<\/span><span class=\"s5\">l<\/span><span class=\"s3\">un<\/span><span class=\"s1\">norte<\/span> <span class=\"s3\">Washington<\/span><span class=\"s6\">y<\/span><span class=\"s1\">s<\/span> <span class=\"s3\">t<\/span><span class=\"s1\">o<\/span> <span class=\"s7\">metro<\/span><span class=\"s1\">eet<\/span><span class=\"s3\"> Hola<\/span><span class=\"s1\">s<\/span><span class=\"s3\">\/<\/span><span class=\"s4\">h<\/span><span class=\"s1\">er<\/span> <span class=\"s3\">norte<\/span><span class=\"s2\">mi<\/span><span class=\"s1\">mi<\/span><span class=\"s6\">re<\/span><span class=\"s1\">s<\/span><span class=\"s3\"> y T<\/span><span class=\"s1\">o <\/span><span class=\"s3\">h<\/span><span class=\"s2\">mi<\/span><span class=\"s6\">l<\/span><span class=\"s1\">pags<\/span> <span class=\"s3\">h<\/span><span class=\"s4\">yo<\/span><span class=\"s5\">metro<\/span><span class=\"s3\">\/ h<\/span><span class=\"s1\">er desarrollar.<\/span> <span class=\"s1\">Por favor<\/span> <span class=\"s1\">regreso<\/span> <span class=\"s1\">eso<\/span> <span class=\"s1\">a<\/span> <span class=\"s1\">colegio<\/span> <span class=\"s1\">como<\/span> <span class=\"s1\">pronto<\/span> <span class=\"s1\">como<\/span> <span class=\"s1\">posible.<\/span><\/p>\n<p class=\"p5\"><span class=\"s1\">\u00a1Muchas gracias!<\/span><\/p><\/li><li id=\"field_23_3\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_3'>El nombre del ni\u00f1o<\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_23_3' type='text' value='' class='medium'   tabindex='1'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_4\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_4'>Apodo del ni\u00f1o<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_23_4' type='text' value='' class='medium'   tabindex='2'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_5\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_5'>Nombre de los padres<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_23_5' type='text' value='' class='medium'   tabindex='3'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_6\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_6'>Fecha<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_6' id='input_23_6' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='4'  placeholder='mm\/dd\/aaaa' aria-describedby=\"input_23_6_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_23_6_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_23_6' class='gform_hidden' value='https:\/\/staging.youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_23_7\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_7'>Maestro del ni\u00f1o<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_23_7' type='text' value='' class='medium'   tabindex='5'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_8\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfVive con su hijo?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_23_8'><li class='gchoice gchoice_23_8_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.1' type='checkbox'  value='Both Parents'  id='choice_23_8_1' tabindex='6'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_8_1' id='label_23_8_1' class='gform-field-label gform-field-label--type-inline'>Ambos padres<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_8_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.2' type='checkbox'  value='One Parent'  id='choice_23_8_2' tabindex='7'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_8_2' id='label_23_8_2' class='gform-field-label gform-field-label--type-inline'>Monoparental<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_8_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.3' type='checkbox'  value='Other adults'  id='choice_23_8_3' tabindex='8'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_8_3' id='label_23_8_3' class='gform-field-label gform-field-label--type-inline'>Otros adultos<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_9\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_9'>Por favor especifica<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_9' id='input_23_9' class='textarea medium' tabindex='9'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_10\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_10'>Enumere los nombres y edades de otras personas que viven en su hogar. (Esto me ayudar\u00e1 a escribir los nombres correctamente en las im\u00e1genes que su hijo dibuje sobre su familia).<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_10' id='input_23_10' class='textarea medium' tabindex='10'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_11\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_11'>Mascotas (nombre y tipo de animal)<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_23_11' type='text' value='' class='medium'   tabindex='11'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_12\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_12'>Trabajo del padre<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_23_12' type='text' value='' class='medium'   tabindex='12'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_13\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_13'>Ocupaci\u00f3n de la madre #039; s<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_23_13' type='text' value='' class='medium'   tabindex='13'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_14\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfTiene su hijo una habitaci\u00f3n propia?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_23_14'><li class='gchoice gchoice_23_14_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.1' type='checkbox'  value='Yes'  id='choice_23_14_1' tabindex='14'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_14_1' id='label_23_14_1' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_14_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.2' type='checkbox'  value='No'  id='choice_23_14_2' tabindex='15'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_14_2' id='label_23_14_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_15\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_15'>Si no es as\u00ed, \u00bfcon qui\u00e9n comparte habitaci\u00f3n?<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_23_15' type='text' value='' class='medium'   tabindex='16'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_16\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_16'>\u00bfCu\u00e1les son las actividades e intereses de juego favoritos de su hijo?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_16' id='input_23_16' class='textarea medium' tabindex='17'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_17\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_17'>\u00bfEl ni\u00f1o usa palabras especiales para ir al ba\u00f1o?<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_23_17' type='text' value='' class='medium'   tabindex='18'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_18\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_18'>Programas de televisi\u00f3n favoritos del ni\u00f1o<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_18' id='input_23_18' class='textarea medium' tabindex='19'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_19\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_19'>Horas diarias dedicadas a ver televisi\u00f3n<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_23_19' type='text' value='' class='medium'   tabindex='20'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_20\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfSuele jugar su hijo?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_23_20'><li class='gchoice gchoice_23_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='Alone?'  id='choice_23_20_1' tabindex='21'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_20_1' id='label_23_20_1' class='gform-field-label gform-field-label--type-inline'>\u00bfSolo?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='With a friend?'  id='choice_23_20_2' tabindex='22'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_20_2' id='label_23_20_2' class='gform-field-label gform-field-label--type-inline'>\u00bfCon un amigo?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='With a few friend?'  id='choice_23_20_3' tabindex='23'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_20_3' id='label_23_20_3' class='gform-field-label gform-field-label--type-inline'>\u00bfCon algunos amigos?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_20_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.4' type='checkbox'  value='with younger children?'  id='choice_23_20_4' tabindex='24'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_20_4' id='label_23_20_4' class='gform-field-label gform-field-label--type-inline'>con ni\u00f1os m\u00e1s peque\u00f1os?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_20_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.5' type='checkbox'  value='with older children?'  id='choice_23_20_5' tabindex='25'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_20_5' id='label_23_20_5' class='gform-field-label gform-field-label--type-inline'>con ni\u00f1os mayores?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_20_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.6' type='checkbox'  value='with children the same age?'  id='choice_23_20_6' tabindex='26'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_20_6' id='label_23_20_6' class='gform-field-label gform-field-label--type-inline'>con ni\u00f1os de la misma edad?<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_21\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_21'>\u00bfTiene el ni\u00f1o miedos decididos? \u00bfEntonces qu\u00e9?<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_23_21' type='text' value='' class='medium'   tabindex='27'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_22\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_22'>\u00bfQu\u00e9 responsabilidades tiene su hijo en casa?<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_23_22' type='text' value='' class='medium'   tabindex='28'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_24\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_24'>\u00bfCu\u00e1l es tu mayor problema de disciplina?<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_23_24' type='text' value='' class='medium'   tabindex='29'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_25\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_25'>\u00bfCu\u00e1l es la historia, el tipo de historia o el libro favorito de su hijo?<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_23_25' type='text' value='' class='medium'   tabindex='30'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_26\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_26'>\u00bfTuvo su hijo un parto prematuro o dif\u00edcil que pueda indicar retrasos cognitivos?<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_23_26' type='text' value='' class='medium'   tabindex='31'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_27\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_27'>\u00bfEs el ingl\u00e9s el idioma principal que se habla en el hogar? Si no es as\u00ed, \u00bfqu\u00e9 es?<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_23_27' type='text' value='' class='medium'   tabindex='32'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_28\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_28'>\u00bfSu hijo habla ingl\u00e9s? \u00bfEntender ingl\u00e9s?<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_23_28' type='text' value='' class='medium'   tabindex='33'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_29\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_29'>\u00bfC\u00f3mo se siente su hijo al venir a la escuela?<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_23_29' type='text' value='' class='medium'   tabindex='34'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_30\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_30'>\u00bfQu\u00e9 espera que su hijo aprenda este a\u00f1o?<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_23_30' type='text' value='' class='medium'   tabindex='35'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_31\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_31'>Haga comentarios sobre cualquier otra cosa que crea que necesito saber sobre su hijo.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_23_31' class='textarea medium' tabindex='36'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_32\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p class=\"p1\"><span class=\"s1\">Nuestro objetivo es fomentar el sentido de pertenencia, promover el aprecio por los dem\u00e1s y enriquecer las experiencias de los ni\u00f1os al integrar en nuestro plan de estudios actividades e informaci\u00f3n que reflejen los antecedentes individuales de nuestros ni\u00f1os.<span class=\"Apple-converted-space\">\u00a0 <\/span>Una forma en que podemos hacer esto es aprendiendo sobre los antecedentes familiares de cada ni\u00f1o, las fiestas celebradas y las tradiciones. T\u00f3mese unos minutos para compartir con nosotros sus d\u00edas o actividades especiales en familia y c\u00f3mo se llevan a cabo en su hogar.<\/span><\/p><\/li><li id=\"field_23_33\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_33'>\u00bfQu\u00e9 idiomas adem\u00e1s del ingl\u00e9s hablan los miembros de la familia que rodean a su hijo?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_33' id='input_23_33' class='textarea medium' tabindex='37'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_34\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_34'>\u00bfSu hijo tiene alguna discapacidad f\u00edsica o de aprendizaje? Si es as\u00ed, describa<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_23_34' class='textarea medium' tabindex='38'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_35\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_35'>\u00bfHay alg\u00fan miembro de la familia con discapacidades que pueda afectar directamente la vida diaria de su hijo (por ejemplo, un abuelo sordo, un padre en silla de ruedas, etc.)?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_23_35' class='textarea medium' tabindex='39'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_36\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_36'>\u00bfQu\u00e9 informaci\u00f3n sobre los antecedentes y la cultura de su familia le gustar\u00eda compartir con nosotros?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_36' id='input_23_36' class='textarea medium' tabindex='40'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_37\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_37'>\u00bfCu\u00e1les son las fiestas, los d\u00edas especiales o las tradiciones en las que participa su familia?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_37' id='input_23_37' class='textarea medium' tabindex='41'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_38\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_38'>\u00bfHay alimentos, canciones, elementos o s\u00edmbolos especiales que incluya en su celebraci\u00f3n de momentos familiares especiales?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_38' id='input_23_38' class='textarea medium' tabindex='42'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_39\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_39'>\u00bfTiene su hijo alguna restricci\u00f3n diet\u00e9tica debido a alergias, intolerancias, preferencias familiares o religiosas? Si es as\u00ed, \u00bfqu\u00e9 est\u00e1 restringido?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_39' id='input_23_39' class='textarea medium' tabindex='43'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_40\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_40'>\u00bfHay actividades de la cultura o tradiciones de su familia que le gustar\u00eda compartir con el sal\u00f3n de clases de su hijo?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_40' id='input_23_40' class='textarea medium' tabindex='44'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_41\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_41'>\u00bfHay actividades de la cultura o tradiciones de su familia que le gustar\u00eda compartir con el sal\u00f3n de clases de su hijo?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_41' id='input_23_41' class='textarea medium' tabindex='45'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_42\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_42'>Haga comentarios sobre cualquier otra cosa que crea que necesito saber sobre su hijo.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_42' id='input_23_42' class='textarea medium' tabindex='46'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_43\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_43'>\u00bfCu\u00e1les son sus puntos fuertes?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_43' id='input_23_43' class='textarea medium' tabindex='47'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_44\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_44'>\u00bfCu\u00e1les son las \u00e1reas de debilidad? \u00bfEn qu\u00e9 te gustar\u00eda que tu hijo mejorara?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_44' id='input_23_44' class='textarea medium' tabindex='48'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_45\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_45'>Mi hijo aprende mejor cuando el maestro es\u2026.<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_23_45' type='text' value='' class='medium'   tabindex='49'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_46\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_46'>Mi hijo no funciona bien con ...<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_23_46' type='text' value='' class='medium'   tabindex='50'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_47\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_47'>\u00bfCu\u00e1l es la mejor forma de motivar a su hijo?<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_23_47' type='text' value='' class='medium'   tabindex='51'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_48\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_48'>\u00bfQu\u00e9 esperas en YMIM?<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_23_48' type='text' value='' class='medium'   tabindex='52'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_49\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_49'>\u00bfC\u00f3mo le gustar\u00eda participar en la educaci\u00f3n de su hijo?<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_23_49' type='text' value='' class='medium'   tabindex='53'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_50\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_50'>What is your preferred method of communication (email, phone call, meeting, note\u2026)___<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_23_50' type='text' value='' class='medium'   tabindex='54'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_51\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/www.youngmindsinmotion.com\/wp-content\/uploads\/2020\/10\/Screenshot-2020-10-21-at-7.32.07-PM.png\"><img decoding=\"async\" src=\"https:\/\/www.youngmindsinmotion.com\/wp-content\/uploads\/2020\/08\/Screenshot-2020-08-01-at-9.44.15-PM.png\"><\/li><li id=\"field_23_52\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_52'>Date ASQ Completed:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_52' id='input_23_52' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon' tabindex='55'  placeholder='dd\/mm\/aaaa' aria-describedby=\"input_23_52_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_23_52_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_23_52' class='gform_hidden' value='https:\/\/staging.youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_23_53\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_53'>Fecha de nacimiento del ni\u00f1o:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_53' id='input_23_53' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='56'  placeholder='mm\/dd\/aaaa' aria-describedby=\"input_23_53_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_23_53_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_23_53' class='gform_hidden' value='https:\/\/staging.youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_23_54\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >\u00bfEs un chico o una chica?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_54'>\n\t\t\t<li class='gchoice gchoice_23_54_0'>\n\t\t\t\t<input name='input_54' type='radio' value='Boy'  id='choice_23_54_0' tabindex='57'   \/>\n\t\t\t\t<label for='choice_23_54_0' id='label_23_54_0' class='gform-field-label gform-field-label--type-inline'>Ni\u00f1o<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_54_1'>\n\t\t\t\t<input name='input_54' type='radio' value='Girl'  id='choice_23_54_1' tabindex='58'   \/>\n\t\t\t\t<label for='choice_23_54_1' id='label_23_54_1' class='gform-field-label gform-field-label--type-inline'>Ni\u00f1a<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_55\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Person filling out Questionnaire<\/h3><\/li><li id=\"field_23_56\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_56'>First Name<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_23_56' type='text' value='' class='medium'   tabindex='59'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_57\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_57'>Middle Initial<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_23_57' type='text' value='' class='medium'   tabindex='60'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_58\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_58'>Last Name<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_23_58' type='text' value='' class='medium'   tabindex='61'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_59\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_59'>Street Address<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_59' id='input_23_59' class='textarea medium' tabindex='62'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_60\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Relacion hac\u00eda el ni\u00f1o:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_60'>\n\t\t\t<li class='gchoice gchoice_23_60_0'>\n\t\t\t\t<input name='input_60' type='radio' value='Parent'  id='choice_23_60_0' tabindex='63'   \/>\n\t\t\t\t<label for='choice_23_60_0' id='label_23_60_0' class='gform-field-label gform-field-label--type-inline'>Parent<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_60_1'>\n\t\t\t\t<input name='input_60' type='radio' value='Guardian'  id='choice_23_60_1' tabindex='64'   \/>\n\t\t\t\t<label for='choice_23_60_1' id='label_23_60_1' class='gform-field-label gform-field-label--type-inline'>Guardian<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_60_2'>\n\t\t\t\t<input name='input_60' type='radio' value='Teacher'  id='choice_23_60_2' tabindex='65'   \/>\n\t\t\t\t<label for='choice_23_60_2' id='label_23_60_2' class='gform-field-label gform-field-label--type-inline'>Teacher<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_60_3'>\n\t\t\t\t<input name='input_60' type='radio' value='Child Care Provider'  id='choice_23_60_3' tabindex='66'   \/>\n\t\t\t\t<label for='choice_23_60_3' id='label_23_60_3' class='gform-field-label gform-field-label--type-inline'>Child Care Provider<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_60_4'>\n\t\t\t\t<input name='input_60' type='radio' value='Grandparent or other relative'  id='choice_23_60_4' tabindex='67'   \/>\n\t\t\t\t<label for='choice_23_60_4' id='label_23_60_4' class='gform-field-label gform-field-label--type-inline'>Grandparent or other relative<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_60_5'>\n\t\t\t\t<input name='input_60' type='radio' value='Foster Parent'  id='choice_23_60_5' tabindex='68'   \/>\n\t\t\t\t<label for='choice_23_60_5' id='label_23_60_5' class='gform-field-label gform-field-label--type-inline'>Foster Parent<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_60_6'>\n\t\t\t\t<input name='input_60' type='radio' value='gf_other_choice'  id='choice_23_60_6' tabindex='69'  onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_23_60_other' name='input_60_other' type='text' value='Otro' aria-label='Otro' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Otro\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Otro\"); }' tabindex='69'  \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_61\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_61'>City :<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_23_61' type='text' value='' class='medium'   tabindex='70'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_62\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_62'>State \/ Province:<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_23_62' type='text' value='' class='medium'   tabindex='71'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_63\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_63'>Zip \/ Postal Code:<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_23_63' type='text' value='' class='medium'   tabindex='72'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_64\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_64'>Country<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_23_64' type='text' value='' class='medium'   tabindex='73'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_65\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_65'>Home telephone number:<\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_23_65' type='text' value='' class='medium'   tabindex='74'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_66\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_66'>Other telephone number:<\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_23_66' type='text' value='' class='medium'   tabindex='75'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_67\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_67'>Email Address<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_23_67' type='text' value='' class='medium'   tabindex='76'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_68\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_68'>Name of the people assisting in questionnaire completion:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_68' id='input_23_68' class='textarea medium' tabindex='77'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_69\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Program Information <\/h3><\/li><li id=\"field_23_70\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_70'>Child ID #<\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_23_70' type='text' value='' class='medium'   tabindex='78'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_71\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_71'>Program ID #<\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_23_71' type='text' value='' class='medium'   tabindex='79'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_72\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_72'>Program Name<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_23_72' type='text' value='' class='medium'   tabindex='80'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_73\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/www.youngmindsinmotion.com\/wp-content\/uploads\/2020\/10\/Screenshot-2020-10-21-at-8.26.52-PM.png\"><\/li><li id=\"field_23_74\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Puntos importantes para recordar:<\/h2>\n<ul>\n    <li>Pruebe cada actividad con su hijo antes de marcar una respuesta.<\/li>\n<li>Haga que completar este cuestionario sea un juego divertido para usted y su hijo.<\/li>\n<li>Aseg\u00farese de que su hijo no est\u00e9 cansado ni tenga hambre.<\/li>\n<li>Please return this questionnaire by ________________________<\/li><\/li><li id=\"field_23_75\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_75'>Notes<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_75' id='input_23_75' class='textarea medium' tabindex='81'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_77\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >1.   Does your child name at least three items from a common category? For example, if you say to your child, \u201cTell me some things that you can eat,\u201d does your child answer with something like \u201ccookies, eggs, and cereal\u201d? Or if you say, \u201cTell me the names of some animals,\u201d does your child answer with something like \u201ccow, dog, and elephant\u201d?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_77'>\n\t\t\t<li class='gchoice gchoice_23_77_0'>\n\t\t\t\t<input name='input_77' type='radio' value='Yes'  id='choice_23_77_0' tabindex='82'   \/>\n\t\t\t\t<label for='choice_23_77_0' id='label_23_77_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_77_1'>\n\t\t\t\t<input name='input_77' type='radio' value='Sometimes'  id='choice_23_77_1' tabindex='83'   \/>\n\t\t\t\t<label for='choice_23_77_1' id='label_23_77_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_77_2'>\n\t\t\t\t<input name='input_77' type='radio' value='Not Yet'  id='choice_23_77_2' tabindex='84'   \/>\n\t\t\t\t<label for='choice_23_77_2' id='label_23_77_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_78\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >2.   Does your child answer the following questions? (Mark \u201csometimes\u201d if your child answers only one question.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_78'>\n\t\t\t<li class='gchoice gchoice_23_78_0'>\n\t\t\t\t<input name='input_78' type='radio' value='Yes'  id='choice_23_78_0' tabindex='85'   \/>\n\t\t\t\t<label for='choice_23_78_0' id='label_23_78_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_78_1'>\n\t\t\t\t<input name='input_78' type='radio' value='Sometimes'  id='choice_23_78_1' tabindex='86'   \/>\n\t\t\t\t<label for='choice_23_78_1' id='label_23_78_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_78_2'>\n\t\t\t\t<input name='input_78' type='radio' value='Not Yet'  id='choice_23_78_2' tabindex='87'   \/>\n\t\t\t\t<label for='choice_23_78_2' id='label_23_78_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_79\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_79'>\u201cWhat do you do when you are hungry?\u201d (Acceptable answers include \u201cget food,\u201d \u201ceat,\u201d \u201cask for something to eat,\u201d and \u201chave a snack.\u201d) Please write your child\u2019s response:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_79' id='input_23_79' class='textarea medium' tabindex='88'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_80\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_80'>\u201cWhat do you do when you are tired?\u201d (Acceptable answers include \u201ctake a nap,\u201d \u201crest,\u201d \u201cgo to sleep,\u201d \u201cgo to bed,\u201d \u201clie down,\u201d and \u201csit down.\u201d) Please write your child\u2019s response:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_80' id='input_23_80' class='textarea medium' tabindex='89'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_81\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >3.   Does your child tell you at least two things about common objects? For example, if you say to your child, \u201cTell me about your ball,\u201d does she say something like, \u201cIt\u2019s round. I throw it. It\u2019s big\u201d?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_81'>\n\t\t\t<li class='gchoice gchoice_23_81_0'>\n\t\t\t\t<input name='input_81' type='radio' value='Yes'  id='choice_23_81_0' tabindex='90'   \/>\n\t\t\t\t<label for='choice_23_81_0' id='label_23_81_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_81_1'>\n\t\t\t\t<input name='input_81' type='radio' value='Sometimes'  id='choice_23_81_1' tabindex='91'   \/>\n\t\t\t\t<label for='choice_23_81_1' id='label_23_81_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_81_2'>\n\t\t\t\t<input name='input_81' type='radio' value='Not Yet'  id='choice_23_81_2' tabindex='92'   \/>\n\t\t\t\t<label for='choice_23_81_2' id='label_23_81_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_84\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >4.   Does your child use endings of words, such as \u201c-s,\u201d \u201c-ed,\u201d and \u201c-ing\u201d? For example, does your child say things like, \u201cI see two cats,\u201d \u201cI am playing,\u201d or \u201cI kicked the ball\u201d?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_84'>\n\t\t\t<li class='gchoice gchoice_23_84_0'>\n\t\t\t\t<input name='input_84' type='radio' value='Yes'  id='choice_23_84_0' tabindex='93'   \/>\n\t\t\t\t<label for='choice_23_84_0' id='label_23_84_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_84_1'>\n\t\t\t\t<input name='input_84' type='radio' value='Sometimes'  id='choice_23_84_1' tabindex='94'   \/>\n\t\t\t\t<label for='choice_23_84_1' id='label_23_84_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_84_2'>\n\t\t\t\t<input name='input_84' type='radio' value='Not Yet'  id='choice_23_84_2' tabindex='95'   \/>\n\t\t\t\t<label for='choice_23_84_2' id='label_23_84_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_83\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Comunicaci\u00f3n<\/h3> <h5> ( Continued ) <\/h5><\/li><li id=\"field_23_82\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >5.   Without your giving help by pointing or repeating, does your child fol- low three directions that are unrelated to one another? Give all three directions before your child starts. For example, you may ask your child, \u201cClap your hands, walk to the door, and sit down,\u201d or \u201cGive me the pen, open the book, and stand up.\u201d<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_82'>\n\t\t\t<li class='gchoice gchoice_23_82_0'>\n\t\t\t\t<input name='input_82' type='radio' value='Yes'  id='choice_23_82_0' tabindex='96'   \/>\n\t\t\t\t<label for='choice_23_82_0' id='label_23_82_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_82_1'>\n\t\t\t\t<input name='input_82' type='radio' value='Sometimes'  id='choice_23_82_1' tabindex='97'   \/>\n\t\t\t\t<label for='choice_23_82_1' id='label_23_82_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_82_2'>\n\t\t\t\t<input name='input_82' type='radio' value='Not Yet'  id='choice_23_82_2' tabindex='98'   \/>\n\t\t\t\t<label for='choice_23_82_2' id='label_23_82_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_85\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >6.   Does your child use all of the words in a sentence (for example, \u201ca,\u201d \u201cthe,\u201d \u201cam,\u201d \u201cis,\u201d and \u201care\u201d) to make complete sentences, such as \u201cI am going to the park,\u201d or \u201cIs there a toy to play with?\u201d or \u201cAre you coming, too?\u201d<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_85'>\n\t\t\t<li class='gchoice gchoice_23_85_0'>\n\t\t\t\t<input name='input_85' type='radio' value='Yes'  id='choice_23_85_0' tabindex='99'   \/>\n\t\t\t\t<label for='choice_23_85_0' id='label_23_85_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_85_1'>\n\t\t\t\t<input name='input_85' type='radio' value='Sometimes'  id='choice_23_85_1' tabindex='100'   \/>\n\t\t\t\t<label for='choice_23_85_1' id='label_23_85_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_85_2'>\n\t\t\t\t<input name='input_85' type='radio' value='Not Yet'  id='choice_23_85_2' tabindex='101'   \/>\n\t\t\t\t<label for='choice_23_85_2' id='label_23_85_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_96\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_96'>Total de comunicaci\u00f3n<\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_23_96' type='text' value='' class='medium'   tabindex='102'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_86\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>MOTOR BRUTO<\/h3><\/li><li id=\"field_23_87\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >1.   Does your child catch a large ball with both hands? (You should stand about 5 feet away and give your child two or three tries before you mark the answer.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_87'>\n\t\t\t<li class='gchoice gchoice_23_87_0'>\n\t\t\t\t<input name='input_87' type='radio' value='Yes'  id='choice_23_87_0' tabindex='103'   \/>\n\t\t\t\t<label for='choice_23_87_0' id='label_23_87_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_87_1'>\n\t\t\t\t<input name='input_87' type='radio' value='Sometimes'  id='choice_23_87_1' tabindex='104'   \/>\n\t\t\t\t<label for='choice_23_87_1' id='label_23_87_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_87_2'>\n\t\t\t\t<input name='input_87' type='radio' value='Not Yet'  id='choice_23_87_2' tabindex='105'   \/>\n\t\t\t\t<label for='choice_23_87_2' id='label_23_87_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_88\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/www.youngmindsinmotion.com\/wp-content\/uploads\/2020\/08\/Screenshot-2020-08-01-at-8.17.32-PM.png\"><\/li><li id=\"field_23_89\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >2.   Does your child climb the rungs of a ladder of a playground slide and slide down without help?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_89'>\n\t\t\t<li class='gchoice gchoice_23_89_0'>\n\t\t\t\t<input name='input_89' type='radio' value='Yes'  id='choice_23_89_0' tabindex='106'   \/>\n\t\t\t\t<label for='choice_23_89_0' id='label_23_89_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_89_1'>\n\t\t\t\t<input name='input_89' type='radio' value='Sometimes'  id='choice_23_89_1' tabindex='107'   \/>\n\t\t\t\t<label for='choice_23_89_1' id='label_23_89_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_89_2'>\n\t\t\t\t<input name='input_89' type='radio' value='Not Yet'  id='choice_23_89_2' tabindex='108'   \/>\n\t\t\t\t<label for='choice_23_89_2' id='label_23_89_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_90\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >3.   While standing, does your child throw a ball overhand in the direction of a person standing at least 6 feet away? To throw overhand, your child must raise his arm to shoulder height and throw the ball forward. (Dropping the ball or throwing the ball underhand should be scored as \u201cnot yet.\u201d)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_90'>\n\t\t\t<li class='gchoice gchoice_23_90_0'>\n\t\t\t\t<input name='input_90' type='radio' value='Yes'  id='choice_23_90_0' tabindex='109'   \/>\n\t\t\t\t<label for='choice_23_90_0' id='label_23_90_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_90_1'>\n\t\t\t\t<input name='input_90' type='radio' value='Sometimes'  id='choice_23_90_1' tabindex='110'   \/>\n\t\t\t\t<label for='choice_23_90_1' id='label_23_90_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_90_2'>\n\t\t\t\t<input name='input_90' type='radio' value='Not Yet'  id='choice_23_90_2' tabindex='111'   \/>\n\t\t\t\t<label for='choice_23_90_2' id='label_23_90_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_91\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/www.youngmindsinmotion.com\/wp-content\/uploads\/2020\/08\/Screenshot-2020-08-01-at-6.36.06-PM.png\"><\/li><li id=\"field_23_92\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >4.   Does your child hop up and down on either the right or left foot at least one time without losing her balance or falling?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_92'>\n\t\t\t<li class='gchoice gchoice_23_92_0'>\n\t\t\t\t<input name='input_92' type='radio' value='Yes'  id='choice_23_92_0' tabindex='112'   \/>\n\t\t\t\t<label for='choice_23_92_0' id='label_23_92_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_92_1'>\n\t\t\t\t<input name='input_92' type='radio' value='Sometimes'  id='choice_23_92_1' tabindex='113'   \/>\n\t\t\t\t<label for='choice_23_92_1' id='label_23_92_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_92_2'>\n\t\t\t\t<input name='input_92' type='radio' value='Not Yet'  id='choice_23_92_2' tabindex='114'   \/>\n\t\t\t\t<label for='choice_23_92_2' id='label_23_92_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_93\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >5.   Does your child jump forward a distance of 20 inches from a standing position, starting with his feet together?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_93'>\n\t\t\t<li class='gchoice gchoice_23_93_0'>\n\t\t\t\t<input name='input_93' type='radio' value='Yes'  id='choice_23_93_0' tabindex='115'   \/>\n\t\t\t\t<label for='choice_23_93_0' id='label_23_93_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_93_1'>\n\t\t\t\t<input name='input_93' type='radio' value='Sometimes'  id='choice_23_93_1' tabindex='116'   \/>\n\t\t\t\t<label for='choice_23_93_1' id='label_23_93_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_93_2'>\n\t\t\t\t<input name='input_93' type='radio' value='Not Yet'  id='choice_23_93_2' tabindex='117'   \/>\n\t\t\t\t<label for='choice_23_93_2' id='label_23_93_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_94\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >6.   Without holding onto anything, does your child stand on one foot for at least 5 seconds without losing her balance and putting her foot down? (You may give your child two or three tries before you mark the answer.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_94'>\n\t\t\t<li class='gchoice gchoice_23_94_0'>\n\t\t\t\t<input name='input_94' type='radio' value='Yes'  id='choice_23_94_0' tabindex='118'   \/>\n\t\t\t\t<label for='choice_23_94_0' id='label_23_94_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_94_1'>\n\t\t\t\t<input name='input_94' type='radio' value='Sometimes'  id='choice_23_94_1' tabindex='119'   \/>\n\t\t\t\t<label for='choice_23_94_1' id='label_23_94_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_94_2'>\n\t\t\t\t<input name='input_94' type='radio' value='Not Yet'  id='choice_23_94_2' tabindex='120'   \/>\n\t\t\t\t<label for='choice_23_94_2' id='label_23_94_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_95\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/www.youngmindsinmotion.com\/wp-content\/uploads\/2020\/08\/Screenshot-2020-08-01-at-5.02.30-PM.png\"><\/li><li id=\"field_23_97\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_97'>Gross Motar Total<\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_23_97' type='text' value='' class='medium'   tabindex='121'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_98\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Fine Motor <\/h3><\/li><li id=\"field_23_99\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >1.   Does your child put together a five- to seven-piece interlocking puzzle? (If one is not available, take a full-page picture from a magazine or catalog and cut it into six pieces. Does your child put it back together correctly?)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_99'>\n\t\t\t<li class='gchoice gchoice_23_99_0'>\n\t\t\t\t<input name='input_99' type='radio' value='Yes'  id='choice_23_99_0' tabindex='122'   \/>\n\t\t\t\t<label for='choice_23_99_0' id='label_23_99_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_99_1'>\n\t\t\t\t<input name='input_99' type='radio' value='Sometimes'  id='choice_23_99_1' tabindex='123'   \/>\n\t\t\t\t<label for='choice_23_99_1' id='label_23_99_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_99_2'>\n\t\t\t\t<input name='input_99' type='radio' value='Not Yet'  id='choice_23_99_2' tabindex='124'   \/>\n\t\t\t\t<label for='choice_23_99_2' id='label_23_99_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_100\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >2.   Using child-safe scissors, does your child cut a paper in half on a more or less straight line, making the blades go up and down? (Carefully watch your child\u2019s use of scissors for safety reasons.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_100'>\n\t\t\t<li class='gchoice gchoice_23_100_0'>\n\t\t\t\t<input name='input_100' type='radio' value='Yes'  id='choice_23_100_0' tabindex='125'   \/>\n\t\t\t\t<label for='choice_23_100_0' id='label_23_100_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_100_1'>\n\t\t\t\t<input name='input_100' type='radio' value='Sometimes'  id='choice_23_100_1' tabindex='126'   \/>\n\t\t\t\t<label for='choice_23_100_1' id='label_23_100_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_100_2'>\n\t\t\t\t<input name='input_100' type='radio' value='Not Yet'  id='choice_23_100_2' tabindex='127'   \/>\n\t\t\t\t<label for='choice_23_100_2' id='label_23_100_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_101\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/www.youngmindsinmotion.com\/wp-content\/uploads\/2020\/08\/Screenshot-2020-08-01-at-6.43.52-PM.png\"><\/li><li id=\"field_23_102\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >3.   Using the shapes below to look at, does your child copy at least three shapes onto a large piece of paper using a pencil, crayon, or pen, with- out tracing? (Your child\u2019s drawings should look similar to the design of the shapes below, but they may be different in size.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_102'>\n\t\t\t<li class='gchoice gchoice_23_102_0'>\n\t\t\t\t<input name='input_102' type='radio' value='Yes'  id='choice_23_102_0' tabindex='128'   \/>\n\t\t\t\t<label for='choice_23_102_0' id='label_23_102_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_102_1'>\n\t\t\t\t<input name='input_102' type='radio' value='Sometimes'  id='choice_23_102_1' tabindex='129'   \/>\n\t\t\t\t<label for='choice_23_102_1' id='label_23_102_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_102_2'>\n\t\t\t\t<input name='input_102' type='radio' value='Not Yet'  id='choice_23_102_2' tabindex='130'   \/>\n\t\t\t\t<label for='choice_23_102_2' id='label_23_102_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_103\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/www.youngmindsinmotion.com\/wp-content\/uploads\/2020\/10\/Screenshot-2020-10-21-at-10.41.07-PM.png\"><\/li><li id=\"field_23_104\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >4.   Does your child unbutton one or more buttons? (Your child may use his own clothing or a doll\u2019s clothing.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_104'>\n\t\t\t<li class='gchoice gchoice_23_104_0'>\n\t\t\t\t<input name='input_104' type='radio' value='Yes'  id='choice_23_104_0' tabindex='131'   \/>\n\t\t\t\t<label for='choice_23_104_0' id='label_23_104_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_104_1'>\n\t\t\t\t<input name='input_104' type='radio' value='Sometimes'  id='choice_23_104_1' tabindex='132'   \/>\n\t\t\t\t<label for='choice_23_104_1' id='label_23_104_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_104_2'>\n\t\t\t\t<input name='input_104' type='radio' value='Not Yet'  id='choice_23_104_2' tabindex='133'   \/>\n\t\t\t\t<label for='choice_23_104_2' id='label_23_104_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_105\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >5.   Does your child draw pictures of people that have at least three of the following features: head, eyes, nose, mouth, neck, hair, trunk, arms, hands, legs, or feet?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_105'>\n\t\t\t<li class='gchoice gchoice_23_105_0'>\n\t\t\t\t<input name='input_105' type='radio' value='Yes'  id='choice_23_105_0' tabindex='134'   \/>\n\t\t\t\t<label for='choice_23_105_0' id='label_23_105_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_105_1'>\n\t\t\t\t<input name='input_105' type='radio' value='Sometimes'  id='choice_23_105_1' tabindex='135'   \/>\n\t\t\t\t<label for='choice_23_105_1' id='label_23_105_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_105_2'>\n\t\t\t\t<input name='input_105' type='radio' value='Not Yet'  id='choice_23_105_2' tabindex='136'   \/>\n\t\t\t\t<label for='choice_23_105_2' id='label_23_105_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_106\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >6.   Does your child color mostly within the lines in a coloring book or within the lines of a 2-inch circle that you draw? (Your child should not go more than 1\/4 inch outside the lines on most of the picture.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_106'>\n\t\t\t<li class='gchoice gchoice_23_106_0'>\n\t\t\t\t<input name='input_106' type='radio' value='Yes'  id='choice_23_106_0' tabindex='137'   \/>\n\t\t\t\t<label for='choice_23_106_0' id='label_23_106_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_106_1'>\n\t\t\t\t<input name='input_106' type='radio' value='Sometimes'  id='choice_23_106_1' tabindex='138'   \/>\n\t\t\t\t<label for='choice_23_106_1' id='label_23_106_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_106_2'>\n\t\t\t\t<input name='input_106' type='radio' value='Not Yet'  id='choice_23_106_2' tabindex='139'   \/>\n\t\t\t\t<label for='choice_23_106_2' id='label_23_106_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_107\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_107'>Fine Motor Total<\/label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_23_107' type='text' value='' class='medium'   tabindex='140'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_108\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3> Problem Solving <\/h3><\/li><li id=\"field_23_109\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >1.   When you say, \u201cSay \u2018five eight three,\u2019\u201d does your child repeat just the three numbers in the same order? Do not repeat the numbers. If neces- sary, try another series of numbers and say, \u201cSay \u2018six nine two.\u2019\u201d (Your child must repeat just one series of three numbers to answer \u201cyes\u201d to this question.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_109'>\n\t\t\t<li class='gchoice gchoice_23_109_0'>\n\t\t\t\t<input name='input_109' type='radio' value='Yes'  id='choice_23_109_0' tabindex='141'   \/>\n\t\t\t\t<label for='choice_23_109_0' id='label_23_109_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_109_1'>\n\t\t\t\t<input name='input_109' type='radio' value='Sometimes'  id='choice_23_109_1' tabindex='142'   \/>\n\t\t\t\t<label for='choice_23_109_1' id='label_23_109_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_109_2'>\n\t\t\t\t<input name='input_109' type='radio' value='Not Yet'  id='choice_23_109_2' tabindex='143'   \/>\n\t\t\t\t<label for='choice_23_109_2' id='label_23_109_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_110\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >2.   When asked, \u201cWhich circle is the smallest?\u201d does your child point to the smallest circle? (Ask this question withoutproviding help by point- ing, gesturing, or looking at the smallest circle.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_110'>\n\t\t\t<li class='gchoice gchoice_23_110_0'>\n\t\t\t\t<input name='input_110' type='radio' value='Yes'  id='choice_23_110_0' tabindex='144'   \/>\n\t\t\t\t<label for='choice_23_110_0' id='label_23_110_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_110_1'>\n\t\t\t\t<input name='input_110' type='radio' value='Sometimes'  id='choice_23_110_1' tabindex='145'   \/>\n\t\t\t\t<label for='choice_23_110_1' id='label_23_110_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_110_2'>\n\t\t\t\t<input name='input_110' type='radio' value='Not Yet'  id='choice_23_110_2' tabindex='146'   \/>\n\t\t\t\t<label for='choice_23_110_2' id='label_23_110_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_112\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/www.youngmindsinmotion.com\/wp-content\/uploads\/2020\/10\/Screenshot-2020-10-21-at-10.52.00-PM.png\"><\/li><li id=\"field_23_113\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >3.   Without your giving help by pointing, does your child follow three dif- ferent directions using the words \u201cunder,\u201d \u201cbetween,\u201d and \u201cmiddle\u201d? For example, ask your child to put the shoe \u201cunder the couch.\u201d Then ask her to put the ball \u201cbetween the chairs\u201d and the book \u201cin the middle of the table.\u201d<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_113'>\n\t\t\t<li class='gchoice gchoice_23_113_0'>\n\t\t\t\t<input name='input_113' type='radio' value='Yes'  id='choice_23_113_0' tabindex='147'   \/>\n\t\t\t\t<label for='choice_23_113_0' id='label_23_113_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_113_1'>\n\t\t\t\t<input name='input_113' type='radio' value='Sometimes'  id='choice_23_113_1' tabindex='148'   \/>\n\t\t\t\t<label for='choice_23_113_1' id='label_23_113_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_113_2'>\n\t\t\t\t<input name='input_113' type='radio' value='Not Yet'  id='choice_23_113_2' tabindex='149'   \/>\n\t\t\t\t<label for='choice_23_113_2' id='label_23_113_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_114\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >4.   When shown objects and asked, \u201cWhat color is this?\u201d does your child name five different colors, like red, blue, yellow, orange, black, white, or pink? (Mark \u201cyes\u201d only if your child answers the question correctly using five colors.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_114'>\n\t\t\t<li class='gchoice gchoice_23_114_0'>\n\t\t\t\t<input name='input_114' type='radio' value='Yes'  id='choice_23_114_0' tabindex='150'   \/>\n\t\t\t\t<label for='choice_23_114_0' id='label_23_114_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_114_1'>\n\t\t\t\t<input name='input_114' type='radio' value='Sometimes'  id='choice_23_114_1' tabindex='151'   \/>\n\t\t\t\t<label for='choice_23_114_1' id='label_23_114_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_114_2'>\n\t\t\t\t<input name='input_114' type='radio' value='Not Yet'  id='choice_23_114_2' tabindex='152'   \/>\n\t\t\t\t<label for='choice_23_114_2' id='label_23_114_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_115\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >5.   Does your child dress up and \u201cplay-act,\u201d pretending to be someone or something else? For example, your child may dress up in different clothes and pretend to be a mommy, daddy, brother, or sister, or an imaginary animal or figure.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_115'>\n\t\t\t<li class='gchoice gchoice_23_115_0'>\n\t\t\t\t<input name='input_115' type='radio' value='Yes'  id='choice_23_115_0' tabindex='153'   \/>\n\t\t\t\t<label for='choice_23_115_0' id='label_23_115_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_115_1'>\n\t\t\t\t<input name='input_115' type='radio' value='Sometimes'  id='choice_23_115_1' tabindex='154'   \/>\n\t\t\t\t<label for='choice_23_115_1' id='label_23_115_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_115_2'>\n\t\t\t\t<input name='input_115' type='radio' value='Not Yet'  id='choice_23_115_2' tabindex='155'   \/>\n\t\t\t\t<label for='choice_23_115_2' id='label_23_115_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_116\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >6.   If you place five objects in front of your child, can he count them by saying, \u201cone, two, three, four, five,\u201d in order? (Ask this question without providing help by pointing, gesturing, or naming.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_116'>\n\t\t\t<li class='gchoice gchoice_23_116_0'>\n\t\t\t\t<input name='input_116' type='radio' value='Yes'  id='choice_23_116_0' tabindex='156'   \/>\n\t\t\t\t<label for='choice_23_116_0' id='label_23_116_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_116_1'>\n\t\t\t\t<input name='input_116' type='radio' value='Sometimes'  id='choice_23_116_1' tabindex='157'   \/>\n\t\t\t\t<label for='choice_23_116_1' id='label_23_116_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_116_2'>\n\t\t\t\t<input name='input_116' type='radio' value='Not Yet'  id='choice_23_116_2' tabindex='158'   \/>\n\t\t\t\t<label for='choice_23_116_2' id='label_23_116_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_117\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3> Personal Social <\/h3><\/li><li id=\"field_23_118\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >1.   Does your child serve herself, taking food from one container to an- other using utensils? For example, does your child use a large spoon to scoop applesauce from a jar into a bowl?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_118'>\n\t\t\t<li class='gchoice gchoice_23_118_0'>\n\t\t\t\t<input name='input_118' type='radio' value='Yes'  id='choice_23_118_0' tabindex='159'   \/>\n\t\t\t\t<label for='choice_23_118_0' id='label_23_118_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_118_1'>\n\t\t\t\t<input name='input_118' type='radio' value='Sometimes'  id='choice_23_118_1' tabindex='160'   \/>\n\t\t\t\t<label for='choice_23_118_1' id='label_23_118_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_118_2'>\n\t\t\t\t<input name='input_118' type='radio' value='Not Yet'  id='choice_23_118_2' tabindex='161'   \/>\n\t\t\t\t<label for='choice_23_118_2' id='label_23_118_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_119\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >1.   Does your child serve herself, taking food from one container to an- other using utensils? For example, does your child use a large spoon to scoop applesauce from a jar into a bowl?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_119'>\n\t\t\t<li class='gchoice gchoice_23_119_0'>\n\t\t\t\t<input name='input_119' type='radio' value='Yes'  id='choice_23_119_0' tabindex='162'   \/>\n\t\t\t\t<label for='choice_23_119_0' id='label_23_119_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_119_1'>\n\t\t\t\t<input name='input_119' type='radio' value='Sometimes'  id='choice_23_119_1' tabindex='163'   \/>\n\t\t\t\t<label for='choice_23_119_1' id='label_23_119_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_119_2'>\n\t\t\t\t<input name='input_119' type='radio' value='Not Yet'  id='choice_23_119_2' tabindex='164'   \/>\n\t\t\t\t<label for='choice_23_119_2' id='label_23_119_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_120\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >2.   Does your child tell you at least four of the following? Please mark the items your child knows.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_120'>\n\t\t\t<li class='gchoice gchoice_23_120_0'>\n\t\t\t\t<input name='input_120' type='radio' value='a. First name'  id='choice_23_120_0' tabindex='165'   \/>\n\t\t\t\t<label for='choice_23_120_0' id='label_23_120_0' class='gform-field-label gform-field-label--type-inline'>a. First name<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_120_1'>\n\t\t\t\t<input name='input_120' type='radio' value='b. Age'  id='choice_23_120_1' tabindex='166'   \/>\n\t\t\t\t<label for='choice_23_120_1' id='label_23_120_1' class='gform-field-label gform-field-label--type-inline'>b. Age<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_120_2'>\n\t\t\t\t<input name='input_120' type='radio' value='c. City she lives in'  id='choice_23_120_2' tabindex='167'   \/>\n\t\t\t\t<label for='choice_23_120_2' id='label_23_120_2' class='gform-field-label gform-field-label--type-inline'>c. City she lives in<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_120_3'>\n\t\t\t\t<input name='input_120' type='radio' value='d. Last Name'  id='choice_23_120_3' tabindex='168'   \/>\n\t\t\t\t<label for='choice_23_120_3' id='label_23_120_3' class='gform-field-label gform-field-label--type-inline'>d. Last Name<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_120_4'>\n\t\t\t\t<input name='input_120' type='radio' value='e. Boy or Girl'  id='choice_23_120_4' tabindex='169'   \/>\n\t\t\t\t<label for='choice_23_120_4' id='label_23_120_4' class='gform-field-label gform-field-label--type-inline'>e. Boy or Girl<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_120_5'>\n\t\t\t\t<input name='input_120' type='radio' value='f. Telephone Number'  id='choice_23_120_5' tabindex='170'   \/>\n\t\t\t\t<label for='choice_23_120_5' id='label_23_120_5' class='gform-field-label gform-field-label--type-inline'>f. Telephone Number<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_121\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >3.   Does your child wash his hands using soap and water and dry off with a towel without help?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_121'>\n\t\t\t<li class='gchoice gchoice_23_121_0'>\n\t\t\t\t<input name='input_121' type='radio' value='Yes'  id='choice_23_121_0' tabindex='171'   \/>\n\t\t\t\t<label for='choice_23_121_0' id='label_23_121_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_121_1'>\n\t\t\t\t<input name='input_121' type='radio' value='Sometimes'  id='choice_23_121_1' tabindex='172'   \/>\n\t\t\t\t<label for='choice_23_121_1' id='label_23_121_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_121_2'>\n\t\t\t\t<input name='input_121' type='radio' value='Not Yet'  id='choice_23_121_2' tabindex='173'   \/>\n\t\t\t\t<label for='choice_23_121_2' id='label_23_121_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_122\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >4.   Does your child tell you the names of two or more playmates, not in- cluding brothers and sisters? (Ask this question without providing help by suggesting names of playmates or friends.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_122'>\n\t\t\t<li class='gchoice gchoice_23_122_0'>\n\t\t\t\t<input name='input_122' type='radio' value='Yes'  id='choice_23_122_0' tabindex='174'   \/>\n\t\t\t\t<label for='choice_23_122_0' id='label_23_122_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_122_1'>\n\t\t\t\t<input name='input_122' type='radio' value='Sometimes'  id='choice_23_122_1' tabindex='175'   \/>\n\t\t\t\t<label for='choice_23_122_1' id='label_23_122_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_122_2'>\n\t\t\t\t<input name='input_122' type='radio' value='Not Yet'  id='choice_23_122_2' tabindex='176'   \/>\n\t\t\t\t<label for='choice_23_122_2' id='label_23_122_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_124\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >5.   Does your child brush her teeth by putting toothpaste on the tooth- brush and brushing all of her teeth without help? (You may still need to check and rebrush your child\u2019s teeth.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_124'>\n\t\t\t<li class='gchoice gchoice_23_124_0'>\n\t\t\t\t<input name='input_124' type='radio' value='Yes'  id='choice_23_124_0' tabindex='177'   \/>\n\t\t\t\t<label for='choice_23_124_0' id='label_23_124_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_124_1'>\n\t\t\t\t<input name='input_124' type='radio' value='Sometimes'  id='choice_23_124_1' tabindex='178'   \/>\n\t\t\t\t<label for='choice_23_124_1' id='label_23_124_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_124_2'>\n\t\t\t\t<input name='input_124' type='radio' value='Not Yet'  id='choice_23_124_2' tabindex='179'   \/>\n\t\t\t\t<label for='choice_23_124_2' id='label_23_124_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_125\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >6.   Does your child dress or undress himself without help (except for snaps, buttons, and zippers)?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_125'>\n\t\t\t<li class='gchoice gchoice_23_125_0'>\n\t\t\t\t<input name='input_125' type='radio' value='Yes'  id='choice_23_125_0' tabindex='180'   \/>\n\t\t\t\t<label for='choice_23_125_0' id='label_23_125_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_125_1'>\n\t\t\t\t<input name='input_125' type='radio' value='Sometimes'  id='choice_23_125_1' tabindex='181'   \/>\n\t\t\t\t<label for='choice_23_125_1' id='label_23_125_1' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_125_2'>\n\t\t\t\t<input name='input_125' type='radio' value='Not Yet'  id='choice_23_125_2' tabindex='182'   \/>\n\t\t\t\t<label for='choice_23_125_2' id='label_23_125_2' class='gform-field-label gform-field-label--type-inline'>A\u00fan no<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_126\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_126'>Personal Social Total<\/label><div class='ginput_container ginput_container_text'><input name='input_126' id='input_23_126' type='text' value='' class='medium'   tabindex='183'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_127\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Overall <\/h3>\n<br\/>\n<p>Parents and providers may use the space below for comments.<\/p><\/li><li id=\"field_23_128\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_128'>1.   Do you think your child hears well? If no, explain:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_128' id='input_23_128' class='textarea medium' tabindex='184'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_129\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_129'>2. Do you think your child talks like other children her age? If no, explain:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_129' id='input_23_129' class='textarea medium' tabindex='185'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_130\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_130'>3.   Can you understand most of what your child says? If no, explain:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_130' id='input_23_130' class='textarea medium' tabindex='186'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_131\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_131'>4.   Can other people understand most of what your child says? If no, explain:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_131' id='input_23_131' class='textarea medium' tabindex='187'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_132\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_132'>5.   Do you think your child walks, runs, and climbs like other children his  age? If no, explain:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_132' id='input_23_132' class='textarea medium' tabindex='188'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_133\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_133'>6.   Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_133' id='input_23_133' class='textarea medium' tabindex='189'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_134\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_134'>7.   Do you have any concerns about your child\u2019s vision? If yes, explain:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_134' id='input_23_134' class='textarea medium' tabindex='190'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_135\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_135'>8.   Has your child had any medical problems in the last several months? If  yes, explain:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_135' id='input_23_135' class='textarea medium' tabindex='191'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_136\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_136'>9.   Do you have any concerns about your child\u2019s behavior? If yes, explain:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_136' id='input_23_136' class='textarea medium' tabindex='192'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_137\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_137'>10.   Does anything about your child worry you? If yes, explain:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_137' id='input_23_137' class='textarea medium' tabindex='193'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_138\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/www.youngmindsinmotion.com\/wp-content\/uploads\/2020\/10\/Screenshot-2020-10-21-at-11.59.56-PM.png\" ><\/li><li id=\"field_23_139\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>1.   SCORE AND TRANSFER TOTALS TO CHART BELOW:<\/h3><br\/>\n<h5>See  ASQ-3 User\u2019s Guide for \ndetails, including how to adjust scores if item\nresponses are missing. Score each item (YES = 10, SOMETIMES = 5, NOT YET = 0). \nAdd item scores, and record each area total.\nIn the chart below, transfer the total scores, and fill in the circles corresponding with the total scores.<\/h5>\n<h4>Areas<\/h4>\n\n<\/li><li id=\"field_23_140\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Communication &quot; Cutt Off: 30.72 &quot;<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_140'>\n\t\t\t<li class='gchoice gchoice_23_140_0'>\n\t\t\t\t<input name='input_140' type='radio' value='0'  id='choice_23_140_0' tabindex='194'   \/>\n\t\t\t\t<label for='choice_23_140_0' id='label_23_140_0' class='gform-field-label gform-field-label--type-inline'>0<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_140_1'>\n\t\t\t\t<input name='input_140' type='radio' value='5'  id='choice_23_140_1' tabindex='195'   \/>\n\t\t\t\t<label for='choice_23_140_1' id='label_23_140_1' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_140_2'>\n\t\t\t\t<input name='input_140' type='radio' value='10'  id='choice_23_140_2' tabindex='196'   \/>\n\t\t\t\t<label for='choice_23_140_2' id='label_23_140_2' class='gform-field-label gform-field-label--type-inline'>10<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_140_3'>\n\t\t\t\t<input name='input_140' type='radio' value='15'  id='choice_23_140_3' tabindex='197'   \/>\n\t\t\t\t<label for='choice_23_140_3' id='label_23_140_3' class='gform-field-label gform-field-label--type-inline'>15<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_140_4'>\n\t\t\t\t<input name='input_140' type='radio' value='20'  id='choice_23_140_4' tabindex='198'   \/>\n\t\t\t\t<label for='choice_23_140_4' id='label_23_140_4' class='gform-field-label gform-field-label--type-inline'>20<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_140_5'>\n\t\t\t\t<input name='input_140' type='radio' value='25'  id='choice_23_140_5' tabindex='199'   \/>\n\t\t\t\t<label for='choice_23_140_5' id='label_23_140_5' class='gform-field-label gform-field-label--type-inline'>25<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_140_6'>\n\t\t\t\t<input name='input_140' type='radio' value='30'  id='choice_23_140_6' tabindex='200'   \/>\n\t\t\t\t<label for='choice_23_140_6' id='label_23_140_6' class='gform-field-label gform-field-label--type-inline'>30<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_140_7'>\n\t\t\t\t<input name='input_140' type='radio' value='35'  id='choice_23_140_7' tabindex='201'   \/>\n\t\t\t\t<label for='choice_23_140_7' id='label_23_140_7' class='gform-field-label gform-field-label--type-inline'>35<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_140_8'>\n\t\t\t\t<input name='input_140' type='radio' value='40'  id='choice_23_140_8' tabindex='202'   \/>\n\t\t\t\t<label for='choice_23_140_8' id='label_23_140_8' class='gform-field-label gform-field-label--type-inline'>40<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_140_9'>\n\t\t\t\t<input name='input_140' type='radio' value='45'  id='choice_23_140_9' tabindex='203'   \/>\n\t\t\t\t<label for='choice_23_140_9' id='label_23_140_9' class='gform-field-label gform-field-label--type-inline'>45<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_140_10'>\n\t\t\t\t<input name='input_140' type='radio' value='50'  id='choice_23_140_10' tabindex='204'   \/>\n\t\t\t\t<label for='choice_23_140_10' id='label_23_140_10' class='gform-field-label gform-field-label--type-inline'>50<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_140_11'>\n\t\t\t\t<input name='input_140' type='radio' value='60'  id='choice_23_140_11' tabindex='205'   \/>\n\t\t\t\t<label for='choice_23_140_11' id='label_23_140_11' class='gform-field-label gform-field-label--type-inline'>60<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_141\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Gross Motor &quot; Cutt Off: 32.78 &quot;<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_141'>\n\t\t\t<li class='gchoice gchoice_23_141_0'>\n\t\t\t\t<input name='input_141' type='radio' value='0'  id='choice_23_141_0' tabindex='206'   \/>\n\t\t\t\t<label for='choice_23_141_0' id='label_23_141_0' class='gform-field-label gform-field-label--type-inline'>0<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_141_1'>\n\t\t\t\t<input name='input_141' type='radio' value='5'  id='choice_23_141_1' tabindex='207'   \/>\n\t\t\t\t<label for='choice_23_141_1' id='label_23_141_1' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_141_2'>\n\t\t\t\t<input name='input_141' type='radio' value='10'  id='choice_23_141_2' tabindex='208'   \/>\n\t\t\t\t<label for='choice_23_141_2' id='label_23_141_2' class='gform-field-label gform-field-label--type-inline'>10<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_141_3'>\n\t\t\t\t<input name='input_141' type='radio' value='15'  id='choice_23_141_3' tabindex='209'   \/>\n\t\t\t\t<label for='choice_23_141_3' id='label_23_141_3' class='gform-field-label gform-field-label--type-inline'>15<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_141_4'>\n\t\t\t\t<input name='input_141' type='radio' value='20'  id='choice_23_141_4' tabindex='210'   \/>\n\t\t\t\t<label for='choice_23_141_4' id='label_23_141_4' class='gform-field-label gform-field-label--type-inline'>20<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_141_5'>\n\t\t\t\t<input name='input_141' type='radio' value='25'  id='choice_23_141_5' tabindex='211'   \/>\n\t\t\t\t<label for='choice_23_141_5' id='label_23_141_5' class='gform-field-label gform-field-label--type-inline'>25<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_141_6'>\n\t\t\t\t<input name='input_141' type='radio' value='30'  id='choice_23_141_6' tabindex='212'   \/>\n\t\t\t\t<label for='choice_23_141_6' id='label_23_141_6' class='gform-field-label gform-field-label--type-inline'>30<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_141_7'>\n\t\t\t\t<input name='input_141' type='radio' value='35'  id='choice_23_141_7' tabindex='213'   \/>\n\t\t\t\t<label for='choice_23_141_7' id='label_23_141_7' class='gform-field-label gform-field-label--type-inline'>35<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_141_8'>\n\t\t\t\t<input name='input_141' type='radio' value='40'  id='choice_23_141_8' tabindex='214'   \/>\n\t\t\t\t<label for='choice_23_141_8' id='label_23_141_8' class='gform-field-label gform-field-label--type-inline'>40<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_141_9'>\n\t\t\t\t<input name='input_141' type='radio' value='45'  id='choice_23_141_9' tabindex='215'   \/>\n\t\t\t\t<label for='choice_23_141_9' id='label_23_141_9' class='gform-field-label gform-field-label--type-inline'>45<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_141_10'>\n\t\t\t\t<input name='input_141' type='radio' value='50'  id='choice_23_141_10' tabindex='216'   \/>\n\t\t\t\t<label for='choice_23_141_10' id='label_23_141_10' class='gform-field-label gform-field-label--type-inline'>50<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_141_11'>\n\t\t\t\t<input name='input_141' type='radio' value='60'  id='choice_23_141_11' tabindex='217'   \/>\n\t\t\t\t<label for='choice_23_141_11' id='label_23_141_11' class='gform-field-label gform-field-label--type-inline'>60<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_142\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Fine Motor &quot; Cutt Off: 15.81 &quot;<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_142'>\n\t\t\t<li class='gchoice gchoice_23_142_0'>\n\t\t\t\t<input name='input_142' type='radio' value='0'  id='choice_23_142_0' tabindex='218'   \/>\n\t\t\t\t<label for='choice_23_142_0' id='label_23_142_0' class='gform-field-label gform-field-label--type-inline'>0<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_142_1'>\n\t\t\t\t<input name='input_142' type='radio' value='5'  id='choice_23_142_1' tabindex='219'   \/>\n\t\t\t\t<label for='choice_23_142_1' id='label_23_142_1' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_142_2'>\n\t\t\t\t<input name='input_142' type='radio' value='10'  id='choice_23_142_2' tabindex='220'   \/>\n\t\t\t\t<label for='choice_23_142_2' id='label_23_142_2' class='gform-field-label gform-field-label--type-inline'>10<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_142_3'>\n\t\t\t\t<input name='input_142' type='radio' value='15'  id='choice_23_142_3' tabindex='221'   \/>\n\t\t\t\t<label for='choice_23_142_3' id='label_23_142_3' class='gform-field-label gform-field-label--type-inline'>15<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_142_4'>\n\t\t\t\t<input name='input_142' type='radio' value='20'  id='choice_23_142_4' tabindex='222'   \/>\n\t\t\t\t<label for='choice_23_142_4' id='label_23_142_4' class='gform-field-label gform-field-label--type-inline'>20<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_142_5'>\n\t\t\t\t<input name='input_142' type='radio' value='25'  id='choice_23_142_5' tabindex='223'   \/>\n\t\t\t\t<label for='choice_23_142_5' id='label_23_142_5' class='gform-field-label gform-field-label--type-inline'>25<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_142_6'>\n\t\t\t\t<input name='input_142' type='radio' value='30'  id='choice_23_142_6' tabindex='224'   \/>\n\t\t\t\t<label for='choice_23_142_6' id='label_23_142_6' class='gform-field-label gform-field-label--type-inline'>30<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_142_7'>\n\t\t\t\t<input name='input_142' type='radio' value='35'  id='choice_23_142_7' tabindex='225'   \/>\n\t\t\t\t<label for='choice_23_142_7' id='label_23_142_7' class='gform-field-label gform-field-label--type-inline'>35<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_142_8'>\n\t\t\t\t<input name='input_142' type='radio' value='40'  id='choice_23_142_8' tabindex='226'   \/>\n\t\t\t\t<label for='choice_23_142_8' id='label_23_142_8' class='gform-field-label gform-field-label--type-inline'>40<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_142_9'>\n\t\t\t\t<input name='input_142' type='radio' value='45'  id='choice_23_142_9' tabindex='227'   \/>\n\t\t\t\t<label for='choice_23_142_9' id='label_23_142_9' class='gform-field-label gform-field-label--type-inline'>45<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_142_10'>\n\t\t\t\t<input name='input_142' type='radio' value='50'  id='choice_23_142_10' tabindex='228'   \/>\n\t\t\t\t<label for='choice_23_142_10' id='label_23_142_10' class='gform-field-label gform-field-label--type-inline'>50<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_142_11'>\n\t\t\t\t<input name='input_142' type='radio' value='60'  id='choice_23_142_11' tabindex='229'   \/>\n\t\t\t\t<label for='choice_23_142_11' id='label_23_142_11' class='gform-field-label gform-field-label--type-inline'>60<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_143\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Problem Solving  &quot; Cutt Off: 31.30 &quot;<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_143'>\n\t\t\t<li class='gchoice gchoice_23_143_0'>\n\t\t\t\t<input name='input_143' type='radio' value='0'  id='choice_23_143_0' tabindex='230'   \/>\n\t\t\t\t<label for='choice_23_143_0' id='label_23_143_0' class='gform-field-label gform-field-label--type-inline'>0<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_143_1'>\n\t\t\t\t<input name='input_143' type='radio' value='5'  id='choice_23_143_1' tabindex='231'   \/>\n\t\t\t\t<label for='choice_23_143_1' id='label_23_143_1' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_143_2'>\n\t\t\t\t<input name='input_143' type='radio' value='10'  id='choice_23_143_2' tabindex='232'   \/>\n\t\t\t\t<label for='choice_23_143_2' id='label_23_143_2' class='gform-field-label gform-field-label--type-inline'>10<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_143_3'>\n\t\t\t\t<input name='input_143' type='radio' value='15'  id='choice_23_143_3' tabindex='233'   \/>\n\t\t\t\t<label for='choice_23_143_3' id='label_23_143_3' class='gform-field-label gform-field-label--type-inline'>15<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_143_4'>\n\t\t\t\t<input name='input_143' type='radio' value='20'  id='choice_23_143_4' tabindex='234'   \/>\n\t\t\t\t<label for='choice_23_143_4' id='label_23_143_4' class='gform-field-label gform-field-label--type-inline'>20<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_143_5'>\n\t\t\t\t<input name='input_143' type='radio' value='25'  id='choice_23_143_5' tabindex='235'   \/>\n\t\t\t\t<label for='choice_23_143_5' id='label_23_143_5' class='gform-field-label gform-field-label--type-inline'>25<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_143_6'>\n\t\t\t\t<input name='input_143' type='radio' value='30'  id='choice_23_143_6' tabindex='236'   \/>\n\t\t\t\t<label for='choice_23_143_6' id='label_23_143_6' class='gform-field-label gform-field-label--type-inline'>30<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_143_7'>\n\t\t\t\t<input name='input_143' type='radio' value='35'  id='choice_23_143_7' tabindex='237'   \/>\n\t\t\t\t<label for='choice_23_143_7' id='label_23_143_7' class='gform-field-label gform-field-label--type-inline'>35<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_143_8'>\n\t\t\t\t<input name='input_143' type='radio' value='40'  id='choice_23_143_8' tabindex='238'   \/>\n\t\t\t\t<label for='choice_23_143_8' id='label_23_143_8' class='gform-field-label gform-field-label--type-inline'>40<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_143_9'>\n\t\t\t\t<input name='input_143' type='radio' value='45'  id='choice_23_143_9' tabindex='239'   \/>\n\t\t\t\t<label for='choice_23_143_9' id='label_23_143_9' class='gform-field-label gform-field-label--type-inline'>45<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_143_10'>\n\t\t\t\t<input name='input_143' type='radio' value='50'  id='choice_23_143_10' tabindex='240'   \/>\n\t\t\t\t<label for='choice_23_143_10' id='label_23_143_10' class='gform-field-label gform-field-label--type-inline'>50<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_143_11'>\n\t\t\t\t<input name='input_143' type='radio' value='60'  id='choice_23_143_11' tabindex='241'   \/>\n\t\t\t\t<label for='choice_23_143_11' id='label_23_143_11' class='gform-field-label gform-field-label--type-inline'>60<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_145\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Personal Solcial  &quot; Cutt Off: 26.60 &quot;<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_145'>\n\t\t\t<li class='gchoice gchoice_23_145_0'>\n\t\t\t\t<input name='input_145' type='radio' value='0'  id='choice_23_145_0' tabindex='242'   \/>\n\t\t\t\t<label for='choice_23_145_0' id='label_23_145_0' class='gform-field-label gform-field-label--type-inline'>0<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_145_1'>\n\t\t\t\t<input name='input_145' type='radio' value='5'  id='choice_23_145_1' tabindex='243'   \/>\n\t\t\t\t<label for='choice_23_145_1' id='label_23_145_1' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_145_2'>\n\t\t\t\t<input name='input_145' type='radio' value='10'  id='choice_23_145_2' tabindex='244'   \/>\n\t\t\t\t<label for='choice_23_145_2' id='label_23_145_2' class='gform-field-label gform-field-label--type-inline'>10<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_145_3'>\n\t\t\t\t<input name='input_145' type='radio' value='15'  id='choice_23_145_3' tabindex='245'   \/>\n\t\t\t\t<label for='choice_23_145_3' id='label_23_145_3' class='gform-field-label gform-field-label--type-inline'>15<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_145_4'>\n\t\t\t\t<input name='input_145' type='radio' value='20'  id='choice_23_145_4' tabindex='246'   \/>\n\t\t\t\t<label for='choice_23_145_4' id='label_23_145_4' class='gform-field-label gform-field-label--type-inline'>20<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_145_5'>\n\t\t\t\t<input name='input_145' type='radio' value='25'  id='choice_23_145_5' tabindex='247'   \/>\n\t\t\t\t<label for='choice_23_145_5' id='label_23_145_5' class='gform-field-label gform-field-label--type-inline'>25<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_145_6'>\n\t\t\t\t<input name='input_145' type='radio' value=''  id='choice_23_145_6' tabindex='248'   \/>\n\t\t\t\t<label for='choice_23_145_6' id='label_23_145_6' class='gform-field-label gform-field-label--type-inline'><\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_145_7'>\n\t\t\t\t<input name='input_145' type='radio' value='30'  id='choice_23_145_7' tabindex='249'   \/>\n\t\t\t\t<label for='choice_23_145_7' id='label_23_145_7' class='gform-field-label gform-field-label--type-inline'>30<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_145_8'>\n\t\t\t\t<input name='input_145' type='radio' value='35'  id='choice_23_145_8' tabindex='250'   \/>\n\t\t\t\t<label for='choice_23_145_8' id='label_23_145_8' class='gform-field-label gform-field-label--type-inline'>35<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_145_9'>\n\t\t\t\t<input name='input_145' type='radio' value='40'  id='choice_23_145_9' tabindex='251'   \/>\n\t\t\t\t<label for='choice_23_145_9' id='label_23_145_9' class='gform-field-label gform-field-label--type-inline'>40<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_145_10'>\n\t\t\t\t<input name='input_145' type='radio' value='45'  id='choice_23_145_10' tabindex='252'   \/>\n\t\t\t\t<label for='choice_23_145_10' id='label_23_145_10' class='gform-field-label gform-field-label--type-inline'>45<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_145_11'>\n\t\t\t\t<input name='input_145' type='radio' value='50'  id='choice_23_145_11' tabindex='253'   \/>\n\t\t\t\t<label for='choice_23_145_11' id='label_23_145_11' class='gform-field-label gform-field-label--type-inline'>50<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_145_12'>\n\t\t\t\t<input name='input_145' type='radio' value='60'  id='choice_23_145_12' tabindex='254'   \/>\n\t\t\t\t<label for='choice_23_145_12' id='label_23_145_12' class='gform-field-label gform-field-label--type-inline'>60<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_146\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><\/li><li id=\"field_23_147\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >1.   Hears well?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_147'>\n\t\t\t<li class='gchoice gchoice_23_147_0'>\n\t\t\t\t<input name='input_147' type='radio' value='Yes'  id='choice_23_147_0' tabindex='255'   \/>\n\t\t\t\t<label for='choice_23_147_0' id='label_23_147_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_147_1'>\n\t\t\t\t<input name='input_147' type='radio' value='No'  id='choice_23_147_1' tabindex='256'   \/>\n\t\t\t\t<label for='choice_23_147_1' id='label_23_147_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_149\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >2.   Talks like other children his age?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_149'>\n\t\t\t<li class='gchoice gchoice_23_149_0'>\n\t\t\t\t<input name='input_149' type='radio' value='Yes'  id='choice_23_149_0' tabindex='257'   \/>\n\t\t\t\t<label for='choice_23_149_0' id='label_23_149_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_149_1'>\n\t\t\t\t<input name='input_149' type='radio' value='No'  id='choice_23_149_1' tabindex='258'   \/>\n\t\t\t\t<label for='choice_23_149_1' id='label_23_149_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_148\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >3.   Understand most of what your child says  ?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_148'>\n\t\t\t<li class='gchoice gchoice_23_148_0'>\n\t\t\t\t<input name='input_148' type='radio' value='Yes'  id='choice_23_148_0' tabindex='259'   \/>\n\t\t\t\t<label for='choice_23_148_0' id='label_23_148_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_148_1'>\n\t\t\t\t<input name='input_148' type='radio' value='No'  id='choice_23_148_1' tabindex='260'   \/>\n\t\t\t\t<label for='choice_23_148_1' id='label_23_148_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_150\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >4.   Others understand most of what your child says?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_150'>\n\t\t\t<li class='gchoice gchoice_23_150_0'>\n\t\t\t\t<input name='input_150' type='radio' value='Yes'  id='choice_23_150_0' tabindex='261'   \/>\n\t\t\t\t<label for='choice_23_150_0' id='label_23_150_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_150_1'>\n\t\t\t\t<input name='input_150' type='radio' value='No'  id='choice_23_150_1' tabindex='262'   \/>\n\t\t\t\t<label for='choice_23_150_1' id='label_23_150_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_151\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >5.   Walks, runs, and climbs like other children?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_151'>\n\t\t\t<li class='gchoice gchoice_23_151_0'>\n\t\t\t\t<input name='input_151' type='radio' value='Yes'  id='choice_23_151_0' tabindex='263'   \/>\n\t\t\t\t<label for='choice_23_151_0' id='label_23_151_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_151_1'>\n\t\t\t\t<input name='input_151' type='radio' value='No'  id='choice_23_151_1' tabindex='264'   \/>\n\t\t\t\t<label for='choice_23_151_1' id='label_23_151_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_152\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >6.   Family history of hearing impairment?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_152'>\n\t\t\t<li class='gchoice gchoice_23_152_0'>\n\t\t\t\t<input name='input_152' type='radio' value='Yes'  id='choice_23_152_0' tabindex='265'   \/>\n\t\t\t\t<label for='choice_23_152_0' id='label_23_152_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_152_1'>\n\t\t\t\t<input name='input_152' type='radio' value='No'  id='choice_23_152_1' tabindex='266'   \/>\n\t\t\t\t<label for='choice_23_152_1' id='label_23_152_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_153\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >7.   Concerns about vision?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_153'>\n\t\t\t<li class='gchoice gchoice_23_153_0'>\n\t\t\t\t<input name='input_153' type='radio' value='Yes'  id='choice_23_153_0' tabindex='267'   \/>\n\t\t\t\t<label for='choice_23_153_0' id='label_23_153_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_153_1'>\n\t\t\t\t<input name='input_153' type='radio' value='No'  id='choice_23_153_1' tabindex='268'   \/>\n\t\t\t\t<label for='choice_23_153_1' id='label_23_153_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_154\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >8. Any medical problems?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_154'>\n\t\t\t<li class='gchoice gchoice_23_154_0'>\n\t\t\t\t<input name='input_154' type='radio' value='Yes'  id='choice_23_154_0' tabindex='269'   \/>\n\t\t\t\t<label for='choice_23_154_0' id='label_23_154_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_154_1'>\n\t\t\t\t<input name='input_154' type='radio' value='No'  id='choice_23_154_1' tabindex='270'   \/>\n\t\t\t\t<label for='choice_23_154_1' id='label_23_154_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_156\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >9.   Concerns about behavior?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_156'>\n\t\t\t<li class='gchoice gchoice_23_156_0'>\n\t\t\t\t<input name='input_156' type='radio' value='Yes'  id='choice_23_156_0' tabindex='271'   \/>\n\t\t\t\t<label for='choice_23_156_0' id='label_23_156_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_156_1'>\n\t\t\t\t<input name='input_156' type='radio' value='No'  id='choice_23_156_1' tabindex='272'   \/>\n\t\t\t\t<label for='choice_23_156_1' id='label_23_156_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_157\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >9.   Concerns about behavior?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_157'>\n\t\t\t<li class='gchoice gchoice_23_157_0'>\n\t\t\t\t<input name='input_157' type='radio' value='Yes'  id='choice_23_157_0' tabindex='273'   \/>\n\t\t\t\t<label for='choice_23_157_0' id='label_23_157_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_157_1'>\n\t\t\t\t<input name='input_157' type='radio' value='No'  id='choice_23_157_1' tabindex='274'   \/>\n\t\t\t\t<label for='choice_23_157_1' id='label_23_157_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_158\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >10 Other concerns?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_158'>\n\t\t\t<li class='gchoice gchoice_23_158_0'>\n\t\t\t\t<input name='input_158' type='radio' value='Yes'  id='choice_23_158_0' tabindex='275'   \/>\n\t\t\t\t<label for='choice_23_158_0' id='label_23_158_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_158_1'>\n\t\t\t\t<input name='input_158' type='radio' value='No'  id='choice_23_158_1' tabindex='276'   \/>\n\t\t\t\t<label for='choice_23_158_1' id='label_23_158_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_159\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>ASQ SCORE INTERPRETATION AND RECOMMENDATION FOR FOLLOW-UP<\/h3> <p>You must consider total area scores, overall\nresponses, and other considerations, such as opportunities to practice skills,  to determine the appropriate follow-up. <\/p><\/li><li id=\"field_23_160\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >If the child\u2019s total score is above 40  it is above the cutoff and  the child\u2019s development appears to be on schedule.<\/li><li id=\"field_23_161\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >If the child\u2019s total score is above 15, but less than 40   it is above the cutoff and the child\u2019s development appears to be on schedule.<\/li><li id=\"field_23_162\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >If the child\u2019s total score is below 15, it is below the cutoff. \nFurther assessment with a professional may be needed.<\/li><li id=\"field_23_163\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>4.FOLLOW-UP ACTION TAKEN:<\/h3><p> Fill all that apply<\/p><\/li><li id=\"field_23_164\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_164'>Provide activities and rescreen in ________ months.<\/label><div class='ginput_container ginput_container_text'><input name='input_164' id='input_23_164' type='text' value='' class='medium'   tabindex='277'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_165\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Share results with primary health care provider<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_165'>\n\t\t\t<li class='gchoice gchoice_23_165_0'>\n\t\t\t\t<input name='input_165' type='radio' value='Yes'  id='choice_23_165_0' tabindex='278'   \/>\n\t\t\t\t<label for='choice_23_165_0' id='label_23_165_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_165_1'>\n\t\t\t\t<input name='input_165' type='radio' value='No'  id='choice_23_165_1' tabindex='279'   \/>\n\t\t\t\t<label for='choice_23_165_1' id='label_23_165_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_166\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Refer for (circle all that apply) hearing, vision, and\/or  behavioral screening.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_166'>\n\t\t\t<li class='gchoice gchoice_23_166_0'>\n\t\t\t\t<input name='input_166' type='radio' value='Yes'  id='choice_23_166_0' tabindex='280'   \/>\n\t\t\t\t<label for='choice_23_166_0' id='label_23_166_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_166_1'>\n\t\t\t\t<input name='input_166' type='radio' value='No'  id='choice_23_166_1' tabindex='281'   \/>\n\t\t\t\t<label for='choice_23_166_1' id='label_23_166_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_167\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_167'>Refer to primary health care provider or other community agency  (specify reason):<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_167' id='input_23_167' class='textarea medium' tabindex='282'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_168\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Refer to early intervention\/early childhood special education.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_168'>\n\t\t\t<li class='gchoice gchoice_23_168_0'>\n\t\t\t\t<input name='input_168' type='radio' value='Yes'  id='choice_23_168_0' tabindex='283'   \/>\n\t\t\t\t<label for='choice_23_168_0' id='label_23_168_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_168_1'>\n\t\t\t\t<input name='input_168' type='radio' value='No'  id='choice_23_168_1' tabindex='284'   \/>\n\t\t\t\t<label for='choice_23_168_1' id='label_23_168_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_169\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >No further action taken at this time<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_169'>\n\t\t\t<li class='gchoice gchoice_23_169_0'>\n\t\t\t\t<input name='input_169' type='radio' value='Yes'  id='choice_23_169_0' tabindex='285'   \/>\n\t\t\t\t<label for='choice_23_169_0' id='label_23_169_0' class='gform-field-label gform-field-label--type-inline'>si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_169_1'>\n\t\t\t\t<input name='input_169' type='radio' value='No'  id='choice_23_169_1' tabindex='286'   \/>\n\t\t\t\t<label for='choice_23_169_1' id='label_23_169_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_170\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_170'>Other (specify):<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_170' id='input_23_170' class='textarea medium' tabindex='287'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_23' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Enviar' tabindex='288' \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_23' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_23' id='gform_theme_23' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_23' id='gform_style_settings_23' value='' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_23' 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type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"202\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><input type=\"hidden\" name=\"trp-form-language\" value=\"es\"\/><\/form>\n                        <\/div><script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 23, 'https:\/\/staging.youngmindsinmotion.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_23').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_23');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_23').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = 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