Free Screening Permission Form
Parent Permission
*
Yes, I give permission for my child to be screened, agree to email communications with Children’s Therapy T.E.A.M. and have received a copy of/access to privacy practices.
No, I don't wish to have my child screened at this time.
Location of Screening: (example: Shiloh Christian School, The Kid's Studio Preschool, etc)
*
Possible Area(s) of Need:
*
PT
OT
Speech
ABA
Dyslexia
unsure
Student's Name
*
Date of Birth
*
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Month
-
Day
Year
Teacher
Contact person's name
*
Following the screening, the therapist and school will provide follow-up recommendations to the contact you list here.
Contact's Relation to student
*
Contact's Phone number
*
Format: (000) 000-0000.
Contact's Home Mailing Address
*
include: street, city, state, and zip code
Email
*
example@example.com
This initial screening request was made by:
*
Teacher
Parent
Other
Parent Signature
*
Today's Date
*
/
Month
/
Day
Year
Preview PDF
Submit
Should be Empty: