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  • Screening Request Form

    If you have concerns or questions regarding your child’s development, a screening and consultation at Imagine Pediatric Therapy can be of assistance. Our in-clinic and over the phone screens will help in determining if your child is following developmental milestones or if he/she would benefit from professional therapeutic intervention.

     

    At Imagine Pediatric Therapy, we provide Speech-Language Therapy, Occupational Therapy, and Physical Therapy to children of all ages. Imagine Pediatric Therapy is a place like no other and we are right in your Chicagoland community.

     

    As a parent, you may have concerns if your child is having difficulty with:

    speech development and language development

    attention, self-help, and/or motor skills impacting their participation throughout the day

    functional abilities, motor planning, or gross motor skills navigating their environment

     

    Our certified pediatric therapists provide professional support to enhance these skills and guide them on a path for lifetime progress functionally, academically, and socially.

     

    Our complementary therapy screening is a 10-15 minute assessment of your child’s language, motor, sensory, and/or social developmental skills completed by a certified pediatric speech pathologist, occupational therapist, or physical therapist. Based on this assessment, our qualified and caring team can provide you with professional recommendations regarding your child’s development and whether they would benefit from a more comprehensive and holistic speech, occupational, and/or physical therapy evaluation.

     

    If a full evaluation is recommended following the complementary screening or by your child’s pediatrician, please contact us at 312.588.5050 to schedule an evaluation appointment.

     

  • DOB*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • Format: (000) 000-0000.

  • Privacy

    I understand that my child teacher is aware of my request for screening and Imagine Pediatric Therapy will keep the findings and future communication direct with the family.

  • Consent to Screen

    I do hereby agree and give my consent for Imagine Pediatric Therapy to perform screening for my child in accordance with standards of practice.

  • I have read and agree to the above terms and give my consent to Imagine Pediatric Therapy to perform a screening for my child.

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Desired Screening
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  • Physical Therapy Parent Report

  • Please provide the following information to give us a well-rounded picture of your child before our meeting:

  • Has your child received Physical Therapy or other Therapeutic activities?*
  • Does your child often run into others, bump into furniture, trip over objects?*
  • Does your child have difficulty with jumping jacks or hopscotch?*
  • Does your child have difficulty standing on one foot, trips over own feet, falls over often in the park?*
  • Was your child late to crawl, walk, jump, run, skip, or gallop?*
  • Is your child able to kick to a target, catch with their hands, throw a ball underhand or overhead at least 6 ft?*
  • Does your child struggle to up in gym class or with other peers ?*
  • Does your child know how to climb at the park ?*
  • Does your child use both sides of their body equally?*
  • Does your child walk on their toes or have any other unique movement patterns (W Sit, turn their feet in or out)?*
  • Does your child know how to walk up and down the stairs switching feet with or without railing?*
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  • Speech Therapy Parent Report

  • Please provide the following information to give us a well-rounded picture of your child before our meeting:

  • Has your child received Speech Therapy or other Therapeutic activities?*

  • Speech Production

  • Does your child pronounce sounds in words incorrectly?*
  • Is your child's speech difficult to understand?*
  • Does your child have unusual voice quality?    (hoarse, nasal, loud, etc.)*
  • Does your child repeat sounds, syllables or words, and/or sometimes stop completely?*

  • Language Comprehension

  • Does your child have difficulty understanding/following directions?*
  • Does your child have difficulty understanding stories or conversations?*
  • Does your child experience difficulty remembering details from oral language?*

  • Expressive Language

  • Does your child speak in incomplete or grammatically-incorrect sentences?*
  • Does your child have difficulty re-telling stories or events?*
  • Does your child have difficulty expressing his/her wants, needs, and ideas?*
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