Screen REGISTRATION FORM

The screens take approximately 10-15 minutes per child and are offered to parents for a $30 fee for each screen. If you would like both Speech Therapy and Occupational Therapy screens, select both and the total cost would be $60.

At the end of the screening process, results and recommendations are provided to the parent and the school (with parent permission). If any concerns are noted, recommendations may include an in-depth Occupational Therapy evaluation, a Speech and Language evaluation, and/or a referral to another specialist.
Student Information
Child's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
School
Gender
Screen(s) Requested:
Name of School (If you are a Parent at Winter Garden Academy, please email scheduler@therapywest2.com)
Grade/Classroom
Name of Teacher
Teacher Email
If you child has a diagnosis, please list
Please indicate any concerns you have
Parent/Guardian Information
Parent/Guardian Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship
Payment & Confirmation
Registration for screen is not confirmed until payment is made. A confirmation email will be sent upon receipt of registration form and payment.

Fee is refundable up to 24 hours before screen is completed. Once the screen has been completed, it is non-refundable.

Occupational Therapy Screen$30.00

Quantity

Speech Therapy Screen$30.00

Quantity

Enter coupon

Subtotal Tax Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Student Information