Developmental Pre-Screening Registration
Thank you for your interest in completing an informal developmental screen. You will have the ability to accompany your child and meet with a speech and language therapist, occupational therapist, and/or physical therapist who will perform the screen and collect information from you through an interview. Please fill out the below information in order to assist the therapists with information about your child. Screenings will be conducted at the AVON PUBLIC LIBRARY! Please contact our office at (860)-284-9779 if you have any questions.
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Child's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Caregiver's name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address if different from child's
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Concerns related to age appropriate developmental milestones.
*
Is your child being currently seen by any skilled service providers. (i.e. birth to three, skilled occupational therapist, skilled speech and language therapist, skilled physical therapist, developmental pediatrician, ABA therapy). If yes, please list them below;
*
How did you hear about our developmental screens?
*
Pediatrician/Doctor
Facebook
Instagram
Family or friend
Staff member/flyer in waiting room
Childcare provider
Other
Do you currently have or have you had a child attend Creative Development?
Yes
No
I prefer not to answer
Please list days and times you're available and our office will give you a call to set up a screening time. Thank you!
Submit
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