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NOSHC permission slip -Newman
One form per child
The screening fee is
$25.00
Payment instructions can be found at the bottom of this form
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* Indicates required question
Email
*
Your email
Student's name
*
Your answer
Student's date of birth
*
MM
/
DD
/
YYYY
Student's grade
*
Choose
PK
K
1st
2nd
3rd
4th
5th
6th
7th
Teacher's name/Class code
*
Your answer
Has your child's teacher presented any concerns regarding his/her speech and/or language skills? *
*
Yes
No
If you answered YES to the previous question, please further explain
Your answer
Does your child wear glasses? (If yes, please make sure they bring their glasses to school on the day(s) of the screening)
*
Yes
No
Does your child have a history of ear infections?
*
Yes
No
If you answered YES to the previous question, Please list the date of your child's last ear infection
Your answer
Have Pressure Equalization tubes been placed?
*
Yes
No
If you answered YES to the previous question, please list the date the most recent PE tubes were placed
Your answer
Does your child receive any of the following? (check all that apply)
*
Speech/Language therapy
Occupational therapy
Physical therapy
N/A
Required
If your child is currently enrolled in speech, language, physical, and/or occupational therapy, please briefly explain what goals they are currently addressing in therapy.
Your answer
Is there a second language spoken in the home?
*
Yes
No
If you answered YES to the previous question, please list the languages spoken in the home along with the child's primary language.
Your answer
Do you have concerns in any of the following areas?:
*
Speech/Articulation
Language (receptive, expressive, processing)
Fluency (stuttering)
Voice
Reading decoding
Reading comprehension
Spelling
Vision
Hearing
N/A
Required
Please add any additional concerns
Your answer
Guardian's name who completed this form (By signing this form you are giving permission for NOSHC to screen your child)
*
Your answer
Telephone number
*
Your answer
Does NOSHC have permission to contact you through email?
*
Yes
No
Payment instructions:
1. Copy this link into a new tab
https://pay.xpress-pay.com/org/DEFD86D5510646A
2. Click on patient payment
3. Type your child's name
4. Under account type :
"Newman screening"
5. Screening fee is
$25.00
*
I have submitted my payment online
Send me a copy of my responses.
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