Developmental Red Flags Alert Form
Child's Name
Date of Birth
Parent/Guardian Name
Date of Assessment
Age Group
0-6 months
6-12 months
1-2 years
2-3 years
3-5 years
5 years and above
Observed Developmental Red Flags
Gross Motor Delay
Fine Motor Delay
Language Delay
Social or Emotional Delay
Unusual Behavior
Other
If other, please specify
Specific Observations / Comments
Recommended Action
Assessed By