Between the Lines Interest Form

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Families are encouraged to complete this form. Your name will be added to our waitlist and we will contact you to complete a phone interview. During this call, you can ask questions and learn more about our program.
905 W. Roseburg Ave. Modesto, Ca
Contact us at (209) 408-0957 or btl@cvplayandgrow.com

Email *

Between the Lines is a program designed to provide intense language support to young children, ages 2 to 4 years old. It is a play-based program, offering low-ratio facilitation and training. Parents drop off their child for a 90 minute class. We provide a snack during the class.

If you feel your child does not need this level of support, check out our PreK and Play program. Enroll directly from our website at cvplayandgrow.com.

Parent's Full Name *

Parent's Phone Number *

Child's Full Name

Child's Birthday *

YYYY

Which areas of your child's development are you most concerned about? *

Communication/Language (i.e., saying words or phrases, understanding basic instructions)

Social Skills and Interaction with peers

Gross Motor Skills (i.e., walking, jumping, kicking a ball)

Fine Motor Skills (i.e., holding a crayon, zipping clothes, taking care of self)

Cognitive Skills (i.e., problem solving, matching, completing puzzles, playing with toys appropriately)

Behavior (i.e., following mastered instructions, tantrums, hitting, playing harmoniously with others)

My child does not make eye contact, use language, or communicate in a functional way.

Other:

Required

How would you describe your child's play skills? *

My child plays with cars, baby dolls, action figures, blocks in the appropriate way.

My child plays with a few toys appropriately, or shows little interest in most toys for more than a few seconds.

My child does unusual things with toys, inspects them rather than plays with them, drops them straight down repeatedly, throws them or overall does not know how to play with toys.

My child roams around, and needs constant help to stay entertained; he/she does not truly play with toys for at least 2 minutes.

Other:

Required

How would you describe your child's communication skills? *

My child uses many words to ask for what he/she wants.

My child uses language to label familiar items, 10-20 words.

My child is using some words, he/she mostly communicates with gestures and/or grunting/whining.

My child points and asks for some items.

My child is not yet using true words, he/she is less than 12 months old.

I feel my child is delayed in this area and I would like a speech therapy consultation for my child.

Other:

Required

Service History (describe in "Other") *

My child has never received services for developmental delay.

My child has received services for developmental delay or is currently receiving services.

My child is being assessed or will be assessed for developmental delay.

My child is delayed but I have rejected the IFSP or IEP services.

Other:

Required

Choose the day you prefer: *

Monday 10-12pm

Wednesday 10-12pm

Thursday 10-12pm

Friday 10-12pm

Monday 4:30pm-6:00pm (NOT AVAIL)

Required

Dietary restrictions/Allergies *

None

Allergies are a concern.

Required

I understand that this program is a voluntary, privately-secured supplemental program and is not apart of my child's IFSP or IEP. I am fully responsible for the financial tuition of this program. *

Yes

I am not sure and would like more explanation.

Required

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