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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.

     

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  • 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.

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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:

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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:

  • Speech Production

  • Language Comprehension

  • Expressive Language

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